The Continuum of Rehabilitation for Persons with Traumatic Brain Injury
When individuals with TBI do not need or meet the requirements for acute inpatient rehabilitation or are not able to participate in acute inpatient rehabilitation for financial reasons, but still have needs requiring 24-hour skilled nursing and rehabilitation care, subacute inpatient rehabilitation is an option. This is also a viable option for those who are making progress toward recovery but still have significant deficits requiring inpatient care at a less intense level. As opposed to a typical nursing home, subacute inpatient rehabilitation settings offer a rehabilitation program along with medical care, and the expectation is for the person with TBI to make functional gains toward a safe discharge. These facilities tend to have less physician and nursing coverage per patient and offer less hours and intensity of rehabilitation therapy than acute inpatient rehabilitation facilities, while having longer lengths of stay. As there are TBI acute inpatient rehabilitation programs, there are also TBI specific subacute inpatient rehabilitation programs which are have greater expertise in addressing medical, cognitive, psychosocial, and behavioral issues associated with TBI.
Once a person with TBI is medically stable and has progressed toa level where they are safe in the community (either able to live independently and safely in the community or has an adequate support network to provide the assistance needed at that time to return to the community safely), they are ready for discharge from inpatient rehabilitation care. Options for community integration services may include: independent living, group home, personal assistant services, vocational rehabilitation, etc. Careful education about discharge plans and needed follow-up appointments are important for the person with TBI and their family.
Many individuals who sustain TBI return to productive work, social roles, family responsibilities and their pre-morbid lifestyle. However, some TBI survivors live with residual disability, have unmet care needs, and/or are initially unsuccessful in community re-entry. Those individuals with TBI at risk for unsatisfactory outcomes or with continued rehabilitation needs are candidates for community-integrated rehabilitation.
Lifetime of Care: Community Integrated Rehabilitation
Community integrated rehabilitation (CIR) is a broad term encompassing various approaches and contexts for treatment, with a gradually evolving body of supporting scientific evidence.
CIR is also referred to as post-acute brain injury rehabilitation and generally includes a number of approaches that allow for individuals with TBI to benefit from further rehabilitation after medical stability is established and initial acute (in-hospital) rehabilitation is completed. Specific models of CIR include neurobehavioral programs, residential programs, comprehensive holistic (day treatment) programs and more recently, home-based programs. Neurobehavioral CIR programs have historically focused on treatment of mood, behavior and executive function, while ensuring supervision and safety in a residential, non-hospital setting. Such programs focus on psychosocial outcomes with emphasis on application of behavioral principles and development of functional skills. Neurobehavioral CIR programs typically have treatment teams, utilize direct support personnel as therapeutic extenders, and are often led by neuropsychologists or behavior analysts. Residential CIR programs were initially developed for individuals who required extended comprehensive TBI rehabilitation, but needed 24-hour supervision or did not have access to adequate outpatient/day services. The home-like environment and staff support served to facilitate development of skills needed to negotiate everyday life, easing generalization across community environments. Comprehensive holistic day treatment CIR programs provide a milieu-oriented, multimodal approach with a neuropsychological focus. Interventions target awareness, cognitive functions, social skills and vocational preparation through individual, group and family-involved interventions delivered by a treatment team. Home-based CIR involves a highly variable degree of services and supports for the individual with TBI able to reside in a home environment. Typically, such individuals do not require 24-hour supports or supervision. Home-based CIR may include the spectrum of outpatient services commonly accessed through individual treatment providers or clinics, or minimal professional supports. There is usually no identified ‘treatment team’, although collaboration across a number of health and social service systems may be evident. Behavioral approaches using self-monitoring and cueing are employed, as well as models wherein family members or in-home paraprofessionals are engaged as therapeutic change agents. Additionally, Home-based CIR involves participant education and the growing use of adaptive equipment, telephonic or web-based support, and technological devices. These devices will be the topic of a future article.