The Continuum of Rehabilitation for Persons with Traumatic Brain Injury
Inpatient rehabilitation generally begins following the medical stabilization of the injury at which time the rehabilitation team assesses the individual’s condition, designs and implements rehabilitation interventions and develops a discharge plan. Inpatient rehabilitation is provided while the individual remains in a hospital or other healthcare facility.
For individuals with identified TBI (usually more moderate or severe), a period of acute care stabilization occurs within the hospital. Confusion and fatigue are common, and a broad array of specialists may participate in the evaluation and treatment process. Individuals who continue to have significant complex health needs or are in a coma, may transition to long term acute care hospitals (LTACs). LTACs specialize in medically complex care, such as ventilator weaning and wound care. More often, those with TBI are referred to inpatient or outpatient rehabilitation services depending on the nature and extent of services needed.
Rehabilitation settings are typically characterized by a treatment team approach to meet the complex needs of the person recovering from TBI. The team is usually directed by both a physician specializing in rehabilitation medicine, and a case manager or care coordinator who ensures communication with family members, funders and across the various treatment providers. The rehabilitation team approach allows for focused services delivered by specially trained professionals with knowledge of interventions for TBI related issues. Further, this approach facilitates communication among team members and allows for rapid sharing of goals for treatment that are tailored to each person’s unique rehabilitation needs. Most importantly, the person with TBI and their circle of support is the hub of the team. Although every rehabilitation setting has its own specific structure and team organization, the roles of some of the more common team members in both inpatient and outpatient settings are outlined below.
TBI rehabilitation physicians (physiatrists) specialize in rehabilitation medicine and are responsible for the overall coordination of care both in the inpatient and outpatient settings. They may provide life long medical and medication management and may work with other physician specialists. Neuropsychologists address TBI effects on thinking processes, behavior and emotions. The neuropsychologist conducts detailed assessments and delivers behavioral and cognitive interventions to maximize awareness, adjustment to injury, cognition and overall functioning. Rehabilitation nurses address medical needs as well as safety, self-care, medication administration, proper nutrition, dressing, bowel and bladder functions, and mobility. This is usually done in inpatient settings but visiting nurses can offer services to those at home. Physical therapists evaluate and intervene to enhance mobility, balance, strength, flexibility, coordination, safety and endurance, within a variety of tasks across environments. Occupational therapists evaluate and intervene to decrease difficulties identified in the performance of basic activities of daily living such as feeding, dressing, bathing, and personal grooming. Occupational therapists may also address sensory, perceptual, and cognitive deficits that can interfere with the completion of higher-level activities of daily living such as preparing meals, completing household chores, managing childcare responsibilities, and handling finances. Speech therapists evaluate communication and cognitive abilities after TBI. Many speech therapists also evaluate swallowing functions and provide treatment to improve swallow safety as needed. Recreational, art, and music therapists utilize diverse means to enhance activity, quality of life and therapeutic outcomes, and identify areas of leisure and social interest that enhance independence. Therapeutic activities are selected to address cognitive and behavioral challenges and improve social functioning. Vocational counselors assist with transition back into the workforce or school, as well as to assess for adaptive equipment and workplace modifications to facilitate employment. Social workers/care coordinators/case managers are the communication nexus of the team and may come from social work or nursing backgrounds. They offer supportive counseling to patients and families, address financial and insurance issues, assist with plans regarding post-hospital care and serve as liaisons among the rehabilitation program, insurance carriers, disability offices, and other community resources.