Over the last few decades there has been a dramatic decline in the length of acute rehabilitation stays (LOS) from 20 to 12 days [15]. These changes have impacted the role of neuropsychologists in inpatient rehabilitation settings, shifting the focus away from comprehensive assessments toward identifying the severity of cognitive and neurobehavioral sequelae, preparing patients and families for discharge, and the next phase of the patient’s rehabilitation. If a patient emerges from PTA during their inpatient rehabilitation stay, a more formal assessment of cognitive functioning is possible and appropriate. The period after emergence from PTA represents an early stage of recovery and assessments must be conducted with an appreciation for the fact that cognition will most likely continue to improve. Subsequent evaluations (inpatient or outpatient) may be necessary in order to generate the most meaningful recommendations for the patient, treatment team, and family.

Given the numerous patient-factors (e.g., neurofatigue, reduced tolerance for testing, aphasia, sensory/perceptual difficulties) and institutional limitations (i.e., requirements by insurance/national carriers that patients participate in several hours of therapy daily to justify payment), even more comprehensive inpatient neuropsychometric assessments are typically relatively brief. Such assessments should attempt to estimate a patient’s pre-injury level of intellect and functioning and provide a screening of their capabilities across a number of cognitive domains. While a comprehensive assessment of attention, language, visuoperception, learning and memory, and executive functioning may be ideal, these domains are typically evaluated using abbreviated (and if possible, repeatable) measures such as the Repeatable Battery for Assessment of Neuropsychological Status (RBANS) [16]. An alternative approach may also involve the selective administration of tests/subtests from lengthier test batteries. Inpatient assessments, which are conducted for the purposes of discharge and treatment planning, are most useful when they include a thorough examination of learning, memory, and executive functioning, since these domains have been widely associated with long-term functional outcomes (i.e., return to work and productivity) following TBI [17, 18].

In addition to cognitive sequelae, it is common for individuals in the acute phase of recovery from TBI to experience changes in emotion and behavior. Inpatient neuropsychologists are uniquely qualified to assess mood, coping, and adjustment and determine the potential implication of these factors on the recovery process. As improvement occurs and patients emerge from PTA, survivors often begin to develop a better appreciation of what has happened to them. Assessment of mood and adjustment during this phase of recovery may include a clinical interview with the patient and family, the use of standardized mood questionnaires (e.g., Beck Depression/Anxiety Inventories, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 item), and consultation with other members of the inpatient care team. Standardized mood measures also provide a means of tracking patients’ distress levels/symptoms and providing patients and their families with feedback about changes in mood symptoms over time.

A clinical interview should be used to evaluate a patient’s current mood symptoms, psychiatric and substance abuse history, awareness of the nature/severity of their injury and functional limitations, adjustment to the hospitalization and inpatient therapies, family/support network, and coping strategies. An understanding of past psychiatric and substance abuse difficulties is important in determining whether or not a patient is at greater risk for developing mood symptoms post injury, or relying on maladaptive coping strategies (e.g., substance use) in the post-acute period. Likewise, assessments of family and social support (e.g., friends, religion/faith, community involvement, etc.) help in identifying positive resources the patient can rely on as they transition from the acute to post-acute phase of recovery.

Patients in early recovery may have difficulty articulating their emotions and rating their own mood states. These difficulties can be further complicated by an incomplete awareness of the extent and implications of their injuries. These patients’ mood can often be best assessed by direct observation. Observing the patient while they are involved in therapies or interacting with family members can be one of the most useful means of understanding the patient’s current mood state. Moreover, this approach provides a more naturalistic setting that allows the neuropsychologist to communicate practical recommendations to other team members and the patient’s family.

Since occupational, speech, and physical therapists typically spend significantly more time with patients than neuropsychologists (even in a well-staffed inpatient rehabilitation unit), these professional colleagues may have observed a richer and more extensive sampling of patient behavior. Similarly, given their interactions with patients for up to 12 h at a time, nurses can provide information about episodes of emotional dysregulation (i.e., tearfulness, anger) or signs of emotional distress (e.g., anxiety) during medical procedures and changes in behavior over time. Other team members are likely to have useful insights regarding an individual’s general disposition, engagement, and frustration tolerance during challenging therapeutic exercises. To provide individualized recommendations for treatment, an inpatient neuropsychologist must regularly interact with other team members. By joining the rehabilitation team, speaking in a common language, and working in a truly collaborative manner with the patient and family, neuropsychologists will be well-suited to provide accurate and useful information that facilitates improved treatment outcomes [19].

Recovery following traumatic brain injury extends long past a patient’s discharge from an inpatient rehabilitation unit and often continues for months to years. Given reduced lengths of stay and the artificial nature of the hospital setting, the majority of rehabilitation now takes place in outpatient settings during the post-acute period. With the initiation of outpatient rehabilitation comes a greater need for determining the patient’s level of functioning within the family, social network, and community at large. As a result, neurocognitive assessments in this phase of recovery gradually evolve from describing changes in functioning over time to assessing the impact of ongoing symptoms on an individual’s daily activities and community participation. Outpatient rehabilitation practices are highly individualized and informed by the ongoing neurocognitive sequelae as well as needs of the persons being served.

Traditionally, neuropsychological assessment has focused on correlating brain dysfunction with behavioral changes. Clinically, this often means (1) diagnosing the presence of underlying brain pathology (e.g., learning disability, dementia), and/or (2) describing the level and pattern of impairment associated with a known cause of brain dysfunction (e.g., stroke or TBI). In the post-acute rehabilitation setting there is often little question regarding the cause or etiology of the brain dysfunction. Neuropsychological testing conducted in this setting is often done for a different purpose, which include quantifying or predicting the degree of limitations an individual will experience in everyday life and assisting him/her with learning to compensate for residual limitations. This can be quite challenging given that the pattern of neurocognitive impairment can vary widely as a function of type/severity of injury and associated physical and emotional sequelae. Nonetheless, neuropsychologists are well-suited to (1) assess the cognitive, neurobehavioral, and environmental factors important to recovery, (2) evaluate levels of functioning within larger social contexts, and (3) outline treatment plans that facilitate return to community participation following TBI.

To assist with the conceptualization of physical and mental changes caused by known medical conditions (such as brain injury) and associated changes in functioning, the World Health Organization developed the International Classification of Functioning, Disabilities, and Health [20]. This model classifies the sequelae of brain injury into (1) body functions and structures, (2) activity, and (3) participation. Body functions and structures are measured by the presence of normal or abnormal (impaired) physical or mental functions. Activity limitations are defined by an individual’s inability to complete an activity due to impairments or changes in body functions and structures (e.g., inability to recall appointments, to follow a recipe while cooking, recall a medication regimen, balance a checkbook, etc.). Activity limitations focus on limitations in specific individual activities, in contrast to participation restrictions which involve societal level role fulfillment. Participation restrictions represent a loss or change in social roles due to changes in body functioning and associated activity limitations (e.g., loss of a job or inability to attend college). Participation is typically assessed through patient or family report and measured by the degree to which an individual is (1) an active, productive member of society, and (2) well integrated into family and community life. In other words, participation restrictions reflect whether individuals are limited in their ability to run a household and maintain a network of friends and family, as well as their involvement in productive activities such as employment, education, and volunteer activities.

In the ICF model, there is a dynamic interplay among changes in body functions and structures (physical and cognitive), activity limitations, and the participation restrictions that impact the person’s reintegration into the community. The most recent iteration of the ICF model [21, 22] has shifted its emphasis from solely a medical model to a model which includes a consideration of the environmental and personal factors that impact long-term outcomes. See Fig. 1 for a graphical illustration of the ICF model.

In our view the ICF model provides clarity regarding the role of neuropsychological testing in post-acute settings and a model for identifying the factors that should be considered and assessed as part of any comprehensive evaluation of individuals with TBI. We find this model particularly useful for several specific reasons. As described above, neuropsychological assessment measures impairments (or the lack thereof) in cognitive abilities. While assessment of the presence and degree of cognitive impairment is important in understanding common symptoms following TBI, in most instances it does not directly assess limitations in activity. For example, a patient who is impaired (below the fifth percentile) in the acquisition and retention of items from a word list might be expected to have difficulty correctly learning and implementing a new medication regimen following TBI. While it would be easy to assume that these cognitive impairments would prevent the patient from engaging effectively in this task, our traditional neuropsychological measures do not directly assess an individual’s ability to follow a medication regimen. Nor do they assess other environmental or personal factors that may facilitate or interfere with this process.

According to the ICF model, environmental or situational moderators/factors that may obstruct or facilitate successful completion of an important activity of daily living (i.e., managing medications) need to be considered in order to make truly accurate predictions about functioning. Such factors may include personal history/experience with medication management, the use of compensatory strategies, or environmental supports (i.e., pillbox along with a pager or alarm system). Even when done comprehensively, testing focused solely on measurement of cognitive impairment without considering these other relevant factors, may not accurately predict whether an individual can perform important day-to-day activities.

The ICF model also provides an important tool for understanding the values and mechanism of action for interventions such as cognitive rehabilitation following TBI. There is an ever-growing literature that supports the value of cognitive rehabilitation in helping to diminish the level of activity limitations and participation restrictions after brain injury [23]. These interventions are effective largely because they facilitate the development of behaviors which compensate for changes in mental and cognitive status. In other words, persons undergoing cognitive rehabilitation may experience improvement in functioning without necessarily experiencing any measureable diminution in cognitive impairment. As such, an intervention is successful if it results in improved real world behaviors and increased independence, whether or not there have been changes in neuropsychological performances [2, 24].

Using the ICF model as a template, we will outline an approach for comprehensive assessment at the post-acute stage of recovery and rehabilitation. In order to obtain such a wide breadth of information, a comprehensive outpatient neuropsychological assessment should include information obtained from a review of the patient’s medical record and history (i.e., focused on assessing degree of severity and other aspects of the injury; see Table 2), an interview with the patient and family members/caregivers, and standardized measures of cognitive and overall psychological functioning. We have provided a detailed outline of these important components of the neuropsychological assessment in Table 2