Defining the problem

The goals of an acute rehabilitation stay are to address acute medical needs, therapy needs, and basic activities of daily living (ADLs). Inpatient rehab is not typically to achieve complete independence but does include anything that would allow a person to be independent for more than 24 hours at a time.

This may also include:

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  RTW

  
  
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  School

  
  
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  Managing a household

  
  
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  Engaging independently in productive activity outside a home

  
  
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  Transportation

Goals of higher-level independence are not funded in an inpatient rehabilitation facility (IRF) based on the logic that regaining higher level skills can be achieved without medical oversight. However, the complexity of safely reentering the community needs a coordinated interdisciplinary system of providers and specialists who individualize the care for each acquired brain injury (ABI) patient. One can imagine the difference in skills needed between a nuclear reactor operator and an air traffic controller.

The patient’s primary rehabilitation team works with involved parties to recommend accommodations. Leaving complex executive decision making to the patient in whom these skills (and insight into them) may be lacking is a faulty strategy. Services geared toward higher level independence are difficult to find because they don’t reimburse well enough to be profitable in a for-profit system. These services are either creatively delivered in a well-funded minority or subsidized in nonprofit settings. In either case, only a minority of patients have access to the resource, whether it is because of society’s value on agency or poor funding. Discharging patients before addressing reentry goals is the unfortunate but most common outcome.

Driving laws vary from state to state, but the safety and legality of driving again after brain injury is clearly important. A patient’s safety awareness and deficits should be reviewed in an inpatient setting to determine whether driving is a realistic goal.

Then the therapy team can look at driving readiness from a discipline-specific perspective to include:

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  Safety awareness

  
  
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  Vision

  
  
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  Reaction time

  
  
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  Ability to interpret and see signage

This is followed by an on-the-road assessment, the gold standard of driving readiness testing. At this point, the patient can present to the department of motor vehicles for licensure. The laws regarding how these steps are carried out vary slightly between programs and states.

Some community reentry programs have a teacher or other representative on the rehab team who serves as a liaison between the patient and the school to determine the best course of action. This may include completing coursework in parallel to being in rehab therapy or a return to school program that begins at home if medical complications make school attendance impossible.

Schools can create accommodations such as:

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  Limited classroom time

  
  
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  A live scribe or iPad

  
  
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  Additional time for assignments

  
  
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  Preferential seating

  
  
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  Early access to lecture material

  
  
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  Adjustment to attendance policies

  
  
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  Extended test time

  
  
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  The option to test in a separate environment

Population considerations

Reentry services are most critical for working and school-age individuals where lifetime dollars lost by not returning to the workforce have the biggest societal consequence, to say nothing of impact to patient and family. The Centers for Medicare and Medicaid Services (CMS) leads the industry in what services should be provided. CMS, by design, is only responsible for retirees over age 65 and permanently disabled individuals who are not returning to work. Most private insurances follow basic CMS guidelines, so the expectation to provide reentry services is also largely absent with private funding sources.

Workers’ compensation (WC) and the Department of Defense (DoD) avert that complication by design but have a secondary set of pitfalls associated with secondary gain. We know, for example, that the relationship between employer and employee does not always set the best intentions, with RTW rates plummeting the more time an employee is out of work. Employees are afraid to lose their benefit by RTW too early and not being successful, whereas WC is guarding against malingering and other abuses to the payment model. The ongoing responsibility WC has for its benefactors affords some of the best long-term outcomes, but it can also lead to unnecessary and expensive medical costs and/or litigation.

A review of the literature demonstrates a dearth of evidence that outcomes after TBI can be predicted or improved. ^, Additionally, there is not agreement on what is meant by community integration for research and treatment planning. Recent data from the past 5 years are more optimistic. Return to employment long term after TBI, 6 to 10 years, is more likely with patients who are young or have had milder injury. The more time that passes postinjury, the more difficult it is to have a successful return to work, suggesting a benefit to early rehabilitative efforts, but more research is needed. Developing ways that help differentiate those who will most benefit from resources is important.

There is a complicated network of providers involved in rehabilitative care who all share the onus of developing a successful reentry plan. A study assessing the benefit of VR services in the United Kingdom showed inpatients with moderate to severe TBI who received VR services were 27% more likely to be employed 1 year after discharge with a negligible difference in healthcare costs. Identifying who is most likely to benefit from services may be helpful in determining resource allocation. In patients who sustained an TBI, 53% of participants had returned to work 1 year postinjury. Probabilities of being employed were 95% lower for those who had been unemployed before injury and 74% lower for those with a more severe injury.

Settings in the continuum of care

High comorbidities exist for the population of people recovering from moderate to severe ABI. Hospital readmission rates and secondary medical costs are high for patients with disorders of consciousness (DOC), and they are frequently passed into lower levels of care too soon. It is imperative for a person’s rights and agency to be considered and to be cared for in the appropriate location for their injury type and severity. These patients often continue to improve, and this allows for a rehabilitation team specializing in brain injury medicine (BIM) to identify when to begin reentry specific goals.

The following are settings in which goals may be addressed and some of the strategies that should be employed.

In an IRF, the treatment is a balance between medical necessity and rehabilitation needs—often referred to as the Goldilocks rule . Initiating a community reentry plan is not often a realistic option in most settings. When these goals can be initiated and the resources are in place to begin community reintegration, there are some clear advantages to beginning treatment in an acute rehabilitation setting.

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  First, the inpatient rehabilitation team services are more intensive and communication is more robust, so it is easier to set a plan in motion.

  
  
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  Second, setting expectations early can be beneficial to the patient and family. Opportunities for helping with short-term disability, financial planning, and for more protracted cases stress inoculation or other forms of psychological support are helpful.

  
  
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  Last is identifying the next setting for care for successful reentry. Early intervention equates to better job retention. Resources fade away more rapidly than most families and patients anticipate, so aligning expectations for future care can decrease the shock of discharging.

Postacute residential brain injury settings vary significantly in design and funding. Because this setting is not paid for by CMS and the private insurance industry varies extensively on payer models, there is inconsistent access to the service. These services are designed to help people RTW and gain independence. Settings where reentry services are available can be a critical link between an IRF level of care and reentry goals critical to community independence.

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  In the postacute setting, length of stays for brain injury patients tend to be longer because goals include regaining lost function and new skill acquisition. There is little to no medical training in BIM fellowships and residency training programs about these services. There is opportunity for research and advocacy in this area to potentially increase access to a larger population of people who could benefit from this care. These settings are additionally beneficial because they create structured safe environments where maladaptive behaviors are common and can be addressed more effectively.

  
  
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  Day program services are intensive comprehensive settings for care that can offer many of the benefits of IRFs without the same medical necessity requirements. They are also hard to find because the resource to funding ratio that makes creating successful programs possible is difficult without philanthropy and community support.

  
  
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  Outpatient rehabilitation can vary extensively in design and may approach day program intensity in some settings. When timed well in the recovery course with clear setting of expectations, this can be a powerful part of the treatment spectrum in ABI community reentry. It is a good setting to begin handing off more responsibility to the patient and family/support structure. There is still access to resources with opportunities to test independence, build insight, and identify unexpected areas of need.

Special problems

Injury characteristics are as varied as there are patients. Some injury patterns are encountered frequently enough and present enough challenges that they deserve special discussion.

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  Anticipating difficulties presented by some of these deficits can be used to facilitate a successful reentry or at least identify where caution should be taken before proceeding. For example, a patient who has worked as a librarian for many years may be more successful than anticipated because of their old knowledge and skills, and an on-the-job evaluation may be warranted. A counter example is a former air traffic controller with anosognosia who is sure they can return to work in spite of clear deficits.

  
  
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  Patients with low premorbid level of function and low social support are the poorest outcome predictors for independence after injury. As a result, longer periods of rehabilitation and social work support are often needed. Resilience counseling and psychological support with a focus on the support structure and strategies to build interdependence are needed for success.

  
  
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  Anosognosia is when a patient has complete unawareness of a lost neurological and/or neuropsychological function. It can be better understood as a complete impairment in self-awareness. Many patients will improve with time and build insight progressing to various levels of impaired self-awareness (ISA). This partial syndrome is the area where treatment is targeted. It is important to develop a consistent strategy with the rehabilitation team that includes clear boundaries, maintenance of rapport, and a focus on building awareness. Studies of anosognosia after TBI demonstrate that 33% of severely injured patients resume a reasonably productive lifestyle 2 to 4 years after injury, but when the follow-up is 10 to 15 years, it is less than 10%. Predictors of outcome post TBI for both work and school after 1 year were shown to be more sensitive to self-centeredness and initiation (aka behavioral difficulties) than for neurological symptoms, physical injuries, cognitive difficulties, and emotional difficulties. Only severity of injury or duration of PTA were as predictive of poor outcome. In another prospective study out of the Netherlands, both psychiatric symptoms postinjury and impaired cognition were considered to be the highest risk factors at 3 years of follow-up for unemployment. These findings are consistent with other more recent prospective studies.

  
  
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  Aphasia constitutes a large range of deficits and depending on the presentation can have no impact on reentry goals in some patients and be devastating to independence with others. Communication ability relates significantly to psychosocial functioning at 1 year post TBI, and continued speech therapy can prove beneficial. A delivery driver with expressive deficits or speech apraxia may have specific scripts that he can carry with him and have minimal impact on performance, whereas a waiter may benefit from habilitation and move to working in the kitchen where language skills are not an essential function. Patients with fluent receptive Wernicke’s aphasia are extremely challenging to reintegrate into life and work after injury. This fact is made more challenging given the frequent copresentation of anosognosia with this deficit.

  
  
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  Mood disorders are best treated with neuropsychiatry, neuropsychology, and/or other specialists knowledgeable in the treatment of ABI. The need to tease out depression, anxiety, and manic symptoms from affective dysfunction is important. Pseudobulbar affect, deficits in prosody, abulia, alexithymia, and fatigue can complicate the clinical picture with very different treatments needed for similar clinical presentations. Communicating these findings with the patient, social support structure, and treatment team will help develop effective strategies for treatment. Something as simple as explaining deficits in prosody or loss of the ability to interpret a loved one’s facial expressions can save a marriage or job.

Review questions

• 1.
  

  Large clinical studies show definitively that

  
  
  
  
  • a.
    

    aphasia is the largest barrier to return to work (RTW).

    
    
  • b.
    

    frontal and temporal injuries associated with anosognosia are the largest barrier to short-term RTW.

    
    
  • c.
    

    time to follow commands (TTFC) is the most significant limitation to RTW .

    
    
  • d.
    

    psychiatric illness postinjury is most correlated barrier for RTW .

  
  
  
  
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  Goals of community reentry

  
  
  
  
  • a.
    

    include school, RTW, vocational, and retirement goals.

    
    
  • b.
    

    are covered through Centers for Medicare and Medicaid Services (CMS) reimbursements.

    
    
  • c.
    

    are covered by Department of Vocational Rehabilitation (DVR) support though state and federal funds.

    
    
  • d.
    

    include support in all inpatient rehabilitation facilities (IRFs).

  
  
  
  
• 3.
  

  A variable that adds the most predictive power for RTW includes

  
  
  
  
  • a.
    

    years since injury.

    
    
  • b.
    

    intellectual quotient.

    
    
  • c.
    

    premorbid education.

    
    
  • d.
    

    medical comorbidities.

  
  

Answers on page 399.

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Available on ExpertConsult.com

• 4.
  

  Patients with anosognosia present a particularly difficult problem because

  
  
  
  
  • a.
    

    they are in denial.

    
    
  • b.
    

    anosognosia only occurs with right frontal injuries.

    
    
  • c.
    

    their impaired self-awareness is immune to intervention.

    
    
  • d.
    

    there are no strategies to deal with anosognosia.

  
  
  
  
• 5.
  

  The Department of Vocational Rehabilitation (DVR)

  
  
  
  
  • a.
    

    is available only to anoxic brain injury(ABI) survivors.

    
    
  • b.
    

    has been in existence as long as the Social Security Administration (SSA).

    
    
  • c.
    

    provides support that is rarely accessed by the majority of those who may benefit.

    
    
  • d.
    

    are individualized but not comprehensive.