Value in Brain Injury Healthcare

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BRAIN INJURY professional vol. 15 issue 2

Value in Brain Injury



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BRAIN INJURY professional

vol. 15 issue 2


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Editor in Chief Message


New Books of Interest

Guest Editor’s Message BIP Expert Interview



Value Based Payment: Implications and Challenges for Medical Rehabilitation Gary Ulicny, PhD


Principles-to-Practice: Payment Opportunities for Healthcare Providers Adam Seidner, MD, MPH, CIC


Patient-Centered Care: A Focus on Optimal Recovery John Watts Jr.


Neuro-Net and the Seamless Future for Brain and Spinal Cord Injury Rehabilitation Ann Perkins, MA • Debra Braunling-McMorrow, PhD Deborah Doherty, MD • Ben Dirlikov, MA • Irwin Altman, PhD, MBA

NORTH AMERICAN BRAIN INJURY SOCIETY CHAIRMAN Mariusz Ziejewski, PhD VICE CHAIR Debra Braunling-McMorrow, PhD IMMEDIATE PAST CHAIR Ronald C. Savage, EdD TREASURER Bruce H. Stern, Esq. FAMILY LIAISON Skye MacQueen EXECUTIVE DIRECTOR/ADMINISTRATION Margaret J. Roberts EXECUTIVE DIRECTOR/OPERATIONS J. Charles Haynes, JD MARKETING MANAGER Megan Bell-Johnston GRAPHIC DESIGNER Kristin Odom BRAIN INJURY PROFESSIONAL PUBLISHER J. Charles Haynes, JD EDITOR IN CHIEF Debra Braunling-McMorrow, PhD - USA EDITOR IN CHIEF Nathan Zasler, MD - USA ASSOCIATE EDITOR Juan Arango-Lasprilla, PhD – Spain DESIGN AND LAYOUT Kristin Odom ADVERTISING SALES Megan Bell-Johnston EDITORIAL ADVISORY BOARD Nada Andelic, MD - Norway Philippe Azouvi, MD, PhD - France Mark Bayley, MD - Canada Lucia Braga, PhD - Brazil Ross Bullock, MD, PhD - USA Fofi Constantinidou, PhD, CCC-SLP, CBIS - USA Gordana Devecerski, MD, PhD - Serbia Sung Ho Jang, MD - Republic of Korea Cindy Ivanhoe, MD - USA Inga Koerte, MD, PhD - USA Brad Kurowski, MD, MS - USA Jianan Li, MD, PhD - China Christine MacDonell, FACRM - USA Calixto Machado, MD, PhD - Cuba Barbara O’Connell, OTR, MBA - Ireland Lisandro Olmos, MD - Argentina Ronald Savage, EdD - USA Caroline Schnakers, PhD - USA Olga Svestkova, MD, PhD - Czech Republic Lynne Turner-Stokes, MD - England Olli Tenovuo, MD, PhD - Finland Asha Vas, PhD, OTR - USA Walter Videtta, MD – Argentina Thomas Watanabe, MD – USA Alan Weintraub, MD - USA Sabahat Wasti, MD - Abu Dhabi, UAE Gavin Williams, PhD, FACP - Australia Hal Wortzel, MD - USA Mariusz Ziejewski, PhD - USA EDITORIAL INQUIRIES Managing Editor Brain Injury Professional PO Box 131401, Houston, TX 77219-1401 Tel 713.526.6900 Email: Website: ADVERTISING INQUIRIES Megan Bell-Johnston Brain Injury Professional HDI Publishers PO Box 131401, Houston, TX 77219-1401 Tel 713.526.6900 Email:

Brain Injury Professional is a membership benefit of the North American Brain Injury Society and the International Brain Injury Association

NATIONAL OFFICE North American Brain Injury Society PO Box 1804, Alexandria, VA 22313 Tel 703.960.6500 / Fax 703.960.6603 Website: ISSN 2375-5210 Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2018 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail

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from the

editor in chief

While a number of payment and healthcare service models have been proposed or significantly modified over the last many years, it seems clear that the continued focus on value in healthcare will be a part of any future model. There is also some indication that integrated care delivery models may yield the best outcomes while providing efficiencies of care. Certainly tracking changes in healthcare payment models is a very complex undertaking, equally as challenging is understanding the payer’s definition of a good outcome or value.

Debra Braunling-McMorrow, PhD

Biography Debra Braunling-McMorrow, PhD, is the President and CEO of Learning Services. She serves on the board of the North American Brain Injury Society as Vice Chair. She has served as a chair of the American Academy for the Certification of Brain Injury Specialists (AACBIS), board of executive directors of Brain Injury Association of America, and several national committees, editorial boards, and peer review panels She is a published author and lecturer in the field of brain injury rehabilitation for over 30 years. To contact Dr. McMorrow, please email

We often hear the terms of return on investment, value-added, or value-based used interchangeably, yet as Dr. Michael Choo outlines in his editorial, these are very distinct terms that we need to better understand in order to guide our meeting the value proposition. In this equation, we also need to better understand the relationship between evidence-based practice and value. I think this is one of the most important editions we can publish, but of course I have said that about others. Still the topic of value is one that providers often think they have a clear definition and understanding. Yet across the continuum of care and across constituents, we lack a unified definition of value in brain injury rehabilitation and how we would advocate that the term value be defined. The contributing authors challenge us to get back to the basics of measuring value that is translatable over the person’s entire continuum of care and more importantly across their lifetime. From the payer side, the focus is on understanding the payer’s expectations, the expected metrics and understanding when a provider may not be able to meet expectations. In addition, two articles discuss innovative models to achieve value-based care. In particular, the importance of ensuring the right treatment at the right time and discussing inefficiencies in healthcare as a result of under or over treating, or the lack of coordinated care. I want to thank Dr. Choo for sharing his passion on this topic, his breadth and knowledge of this complex issue, and his ability to draw such a variety of expert authors. NABIS held a very successful Annual Conference on Brain Injury in Houston last March. We thank Jon Silver and his planning committee for organizing a highly educational meeting. Held concurrently with the medical event, the 31st Conference on Legal Issues in Brain Injury enjoyed record attendance thanks to the collective efforts of co-chairs Steward Casper, Simon Forgette, Kenneth Kolpan, and Bruce Stern. Looking ahead, NABIS is excited that the International Brain Injury Association’s 13th World Congress on Brain Injury will be held in Toronto, Canada, in March of next year. The leading global event in the field of brain injury, the World Congress will feature an outstanding faculty of internationally recognized speakers delivering platform lectures, panels and workshops. Under the direction of Chair Nora Cullen, state of the art research will be presented dealing with every aspect of brain injury from coma to community. Readers should note that the abstract submission deadline for the Congress in November 19, 2018. And, as has been an important component of previous events, the Congress presents a variety of networking opportunities designed to form new friendships and foster new collaborations. As an affiliate group of IBIA, NABIS has again been asked to play a leading role in the development of a portion of the content for the 2019 Congress, and NABIS board member Alan Weintraub will be leading that effort for the Society. We are thrilled to also announce that Dr. Weintraub will be leading the committee for the NABIS conference in 2020, so stay tuned for additional details!

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from the

guest editor

U.S healthcare spending reached $3.49 trillion in 2017 and is forecasted to grow another 5.2% in 2018. As healthcare policy debate rages on in Washington, D.C., about how to best rein in and control this unsustainable growth, reality is starting to set in: The prevailing fee-for-service reimbursement may be transitory.


Author Bio Michael Choo, MD is Paradigm Outcomes’ Chief Medical Officer. He maintains relationships with Paradigm’s network of consulting physicians and centers of excellence, and is responsible for enhancing clinical operations and leading research and development. He also teaches emergency medicine, internal medicine, and family practice residents at Wright State University’s Boonshoft School of Medicine. Dr. Choo has an MBA and is an oral board examiner for the American Board of Emergency Medicine, a fellow of the American College of Emergency Physicians, and a fellow and board member of the American Academy of Emergency Medicine.

Particularly in the rehabilitation industry, there is growing need to justify the necessity of interventions by demonstrating the benefits to payers. This is especially challenging for post-acute providers because rehabilitation benefits tend not to be realized immediately, but incrementally over the care continuum. So, how do providers best demonstrate to payers the Return-on-Investment (ROI) or value of rehabilitation services? To start, many of us in healthcare use the terms ROI and value interchangeably to articulate the merits of medical services, but it is important to acknowledge that payers define them distinctly. ROI is a purely financial metric calculating profits or additional revenues acquired from an investment. On the other hand, value is defined as the relative benefit or worth achieved with a given cost or spend, meaning the gains in healthcare are cost avoidance or improved quality outcomes or -- even better – both. This makes the concept of value-based care and value-based reimbursement much more relevant and appropriate for healthcare than ROI. Although the principles of value seem simple and clear, the way forward is arduous because “value” lends itself to many variations and permutations depending upon the stakeholder. Three questions, to begin with: Which variables should be considered in the “quality outcome” numerator? Which carerelated utilizations should be incorporated? And how should the temporal elements be factored into the equation? Dr. Gary Ulicny’s thought-provoking article fundamentally supports the benefits of transitioning to a value-based approach, and he challenges healthcare providers, payers, and policymakers to take action. His article strongly urges rehabilitation providers to consider standardizing clinical outcome measures that are functionally meaningful to patients and family, rather than average Length of Stay. He further emphasizes the providers’ responsibility to promote the level of evidence-based and evidence-informed clinical interventions, while validating the cost effectiveness associated with current and future rehabilitation care approaches. Dr. Ulicny proposes that payers adopt innovative value-based payment incentives to align the providers’ focus on outcomes. His hopes for policymakers are to simplify regulations to be more pragmatic and to encourage provider innovation. Dr. Adam Seidner from The Hartford Financial Services Group, Inc. gives a comprehensive review of the strengths and weaknesses of healthcare payment models from the traditional to the more novel. Dr. Seidner guides providers in preparing for various types of reimbursement models; defining and measuring successful outcomes, and finally in how to engage payers to mutual benefit. The article by John Watts, Jr., CEO of Paradigm Outcomes, provides his perspective gleaned from many years leading large commercial group health payer organizations and other healthcare-related companies. Mr. Watts extols the merits of value-based care and urges healthcare stakeholders to adopt a systematic and integrated expert continuum of care, delivering the right interventions at the right time, providing improved quality of life for injured workers, and increasing value for long-term medical costs. His article offers fundamentals and key attributes of value-based care organizations, such as a culture of accountability and outcomes, and data-utilization methods that drive ultimate value – great outcomes at a lower cost. Sharing the success of Neuro-Net, an integrated network of providers within the post-acute care continuum, Ann Perkins et al, demonstrate how collaboration provides value-based care by improving outcomes and reducing costs for patients with brain and spinal cord injuries. The authors of the article demonstrate that utilizing experts in the care continuum can indeed improve efficiency, effectiveness, and lead to better clinical outcomes. Lastly, Dr. Marc Duerdin offers very insightful perspectives to my interview questions regarding value and rehabilitation needs with Brain Injury conditions. His expertise and wisdom gleaned from his years of clinical practice in rehabilitation as well as his administrative roles in the development and adjudication of payment policies for Medicare and other commercial payers offer a “point of view” for clinical providers to consider going forward. So, enjoy this special summer edition of Brain Injury Professional.

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2002 – 2005. He is also the author of two novels on brain injury, Crashing Minds and Concussion is Forever.


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Value Based Payment: Implications and Challenges for Medical Rehabilitation Gary Ulicny, PhD Changes in health policy over the last several years have caused us to step back and evaluate how we deliver healthcare in the U.S. While the introduction of the Affordable Care Act was primarily to provide insurance to low-income and uninsured Americans, a significant component of the legislation were mandates causing us to rethink how we pay for medical services, including medical rehabilitation. Many studies have shown that the current feefor-service model is both wasteful and expensive. Consequently many experts are calling for a move to value-based care and reimbursement. It is believed that this move will both increase the quality of care and help us to rein in ever-escalating healthcare costs. While others in the healthcare delivery system have embraced these concepts, the field of medical rehabilitation is lagging. Michael Porter (2010), the guru of value-based medicine, defines the concept of value as the relationship between outcomes achieved and the cost to achieve those outcomes, resulting in return on investment (ROI) for all stakeholders. The field of medical rehabilitation has long embraced outcomes as a measuring tool for quality (FIM, Mayo Portland, etc.), however there is very little information examining the cost benefit of rehabilitation. A substantial contributor to this lack of data is our current reimbursement system. The majority of medical rehabilitation services in this country are provided by small inpatient units at local community hospitals or skilled nursing facilities. The predominant payer for these programs is the Center for Medicare Services (CMS), using a reimbursement methodology designed for senior Medicare recipients and the conditions they most often face.

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When the system is used for catastrophic injury such as brain injury, the reimbursement system often defines the treatment plan rather than the needs of the patient. Many of the basic concepts of this system, such as the three-hour rule and designated lengths of stay, have become so entrenched that they affect how we deliver services to people with brain injury. The three-hour rule has become an indicator for rehabilitation readiness not only with CMS but commercial payers have also adopted this as a standard. Colleagues who initially worked on developing the three-hour rule as a standard, suggest it was based on available evidence, however, I can find no definitive studies that indicate that three hours per day is the optimal time period to begin a comprehensive rehab program. In fact, for many patients with brain injury, the inability to tolerate three hours of rehabilitation per day has relegated them to long-term-care facilities, even though they may benefit from some intensive rehabilitation, and worse, many commercial health plan benefits do not permit individuals to transfer back to intensive rehabilitation, even if they begin to emerge. Another troubling aspect of this reimbursement model is that payments have been related to length of stay. As a long-time Commission on Accreditation of Rehabilitation Facilities (CARF) surveyor, it troubles me when I go into an organization and they are celebrating being able to reduce their length of stay to thirteen days. I often ask what their outcomes are and with great pride many reply, “We are right at the national average.� As an industry, is that something we want to strive for -- meeting the national average? As a consumer, I would like to have the opportunity to choose a program that substantially exceeds the national average.

In fact, I have a great deal of difficulty with using an average as a standard of quality. The biggest problem with this reimbursement system is it lumps all patients into one intensity (LOS) of service category. Therapists and administrators are often incentivized to meet these LOS targets so that many individuals who could benefit from longer stays are discharged prematurely. An example of this is, in 2014, the uniform data system (UDS) national average for LOS for a brain injury was 18 days, while the average LOS for brain injury patients in model systems programs was 32 days, a significant difference. While I agree that some of this may be influenced by severity of injury, I can’t help but think that the reimbursement system has some effect on this number.

The major findings of that study are presented it in TABLE 1 below, but they are hardly overwhelming in making a case for inpatient medical rehabilitation, considering that services provided in other locations were substantially less costly. This lack of research demonstrating the cost-effectiveness of medical rehabilitation substantially limits our advocacy efforts moving forward.

One of the saddest things for consumers is that the gold standard for rehabilitation programs is now the US News and World Report annual ranking of rehabilitation facilities, which is solely based on votes from physiatrists across the country. It seems to me that it is only human nature that physiatrists will vote for the place they did their residency, resulting in those programs with the largest Perhaps the most disturbing residency programs being the thing to come out of our highest rated. In the field of reimbursement system is that it, brain injury rehabilitation, these rather than evidence, has shaped rankings don’t take into account our continuum of care, especially many of the high-quality postThe most common value-based for people with brain injury. The hospital care programs that payment methodology is what is being typical continuum of care for are very cost effective (Ashley called a bundled payment. In a bundled rehabilitation has been inpatient, et. al, 2017), which I believe outpatient, and home health, further contributes to many payment, providers receive one case and many commercial health payers’ unwillingness to fund rate payment for the medical episode, plans will only pay for traditional these very valuable programs. for example, a severe brain injury. services such as speech language In addition, letting our current pathology, physical therapy, and reimbursement system dictate occupational therapy delivered our continuum of care may have by licensed professionals. There created a ceiling effect on the is an emerging body of evidence outcome we are able to achieve that shows that post-hospital with people with brain injury by care provided in community settings can substantially improve the limiting the intensity (LOS) of service. outcome of people with brain injuries, yet many payers, including In our fragmented system, most of the post-hospital brain injury CMS, will not pay for the services because payments are tied to rehabilitation providers are for-profit companies that have not the license of facilities that the services are delivered in, rather been extremely receptive to sharing outcomes. While there are than services that will best meet the patient’s needs. Not only some published studies demonstrating outcomes, there is no does this reimbursement system inhibit services that are needed, central data base that allows post-hospital providers to benchmark it also substantially suppresses any efforts to conduct research their performance against other programs. Consequently, from an on innovative ways of delivering care, which again has resulted in advocacy standpoint the best data that we can provide is discharge rehabilitation (which should be a poster child for delivering value) data from inpatient rehabilitation, which really only tells part of the lagging behind other areas of medical care. story. Further compounding this issue is the fact that most inpatient brain injury units use totally different measures than post-hospital As an industry we have contributed to this problem by putting more programs, creating the inability to evaluate the same outcomes over emphasis on protecting the current system than looking at innovative the entire rehabilitation continuum. new models to deliver care. In response to recent efforts at the federal level to implement site neutral payments, where there is The lack of consistent outcome and quality measures will continue one payment methodology regardless of what type of facility the to hamper our ability to make a strong case for a robust continuum care is delivered in, we have responded by citing a study that used of care for people with brain injury. While I understand the need for claims data to attempt to show that services provided in inpatient severity adjustment in data and the rationale for many competitive rehab facilities were substantially better than those provided in other programs’ hesitation to share outcome data, at some point the old settings, such as skilled nursing facilities (Dobsan, Davanzo, 2014). adage, “Our patients are different,” has to go away. Table 1 TABLE 1 Dobson/Davanzo Results IRF vs SNF Patients • IRF Patients – Returned home two weeks earlier – Remained home two months longer – IRF Patients had an 8% lower mortality rate during the 2-­‐year study – IRFs had 5% fewer emergency room readmissions – For 5 of the 13 conditions studied, IRF had fewer hospital readmissions per year – Limitations = Claims not Clinical Data

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As I look back at the many times my organization wrestled with this topic I cannot help but think of my close colleague and friend Michael Jones. Mike has a great gift of looking at very complex issues and coming up with simple solutions. Mike has always said that outcomes should focus on those that provide value (ROI) to all parties involved. He advocated for four simple outcome measures — return to home, amount of assistance needed, return to productive activity, and ongoing medical and re-hospitalization costs. I would add to those community participation, but I believe these simple measures meet the test of being relevant to all stakeholders. First, patients and families want to return home as independently as possible and return to some sort of productive activity. They want to be active members of the community and stay healthy. Second, if we produce good outcomes in all these domains, payers are happy because it reduces costs. Finally, in order to stay in business, it is in the best interest of providers to produce the best possible outcomes and provide the highest value for the people they serve. Until we as an industry, including payers, are able to agree on consistent measures of outcomes and quality, we will never be able to demonstrate our value.

What Does Value-Based Payment in Rehabilitation Look Like? While there is significant conversation about moving toward a value-based payment system, there’s been little discussion of what that would specifically look like, especially in medical rehabilitation. Dejong, (2010) has outlined criteria for value-based payment and I have made a few additions. They include:

Adequate Payment The payment system must be adequate to cover real costs. Providers must be given the opportunity to finish the job. One of the biggest challenges for this model is, “Where does that payment start?” Will payers want to pay for an entire episode of care, which means that the payment would start at the time of injury? In a perfect world, this makes the most sense because you would be able to manage the care throughout the entire continuum. However, knowing the high cost of trauma and acute care, will there be adequate funds left for post-acute providers? In addition, given that our continuum of care is so fragmented, it is likely that the payment would need to be divided by multiple providers who may or may not have any kind of business or communication relationship. A more reasonable model would be to develop a post-acute bundled payment that starts once the patient leaves the acute-care setting. This would force us as an industry to take a new look at our continuum of care and how well it is integrated and focused on returning patients to the community. Providers would either need to develop new services or partner with existing services to create post-acute integrated networks to serve individuals with catastrophic injuries. In these integrated networks, case management would even become a more important service, as the key to survival is ensuring that you move the patient to the least costly level of care but protect the maximum outcome.

Payment Includes Both Incentives and Disincentives Relative to Quality In a value-based payment system, it makes sense that providers would be punished for poor outcomes and preventable complications, and incentivized for producing good outcomes. We know how payers would punish providers, by reducing payments, which CMS has already done for many hospital-acquired complications.

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Very little discussion has focused on how we incentivize providers, how meaningful incentives are determined, and whether payers are willing to embrace those incentives and, more importantly, pay more for good outcomes.

Provides Sufficient Treatment Time Given what we now know about neuroplasticity, it is clear that persons with brain injury can continue to make gains long after the injury. For this reason, payment models should allow sufficient time to adequately address the needs of the patient.

Includes a Sound Severity Adjustment Component One of my biggest fears is that bundled payment models will use existing methods (LOS, RICs) as a starting point. I believe this will significantly impact people with brain injury and other catastrophic injuries. One only has to look at the example I used comparing average UDS lengths of stay to the model systems. This methodology would also eliminate services at most posthospital programs, severely limiting our continuum of care. Not all brain injury patients are the same, and we must have a valid and reliable system for taking that into account.

Must Promote Innovation The most common value-based payment methodology is what is being called a bundled payment. In a bundled payment, providers receive one case rate payment for the medical episode, for example, a severe brain injury. In order for this to work effectively, providers will need to develop new ways of delivering rehabilitation which have historically been dictated by our current reimbursement system. I firmly believe that if you look at how we delivered rehabilitation 20 years ago, it is not much different now. Innovation in medical rehabilitation has primarily focused on new technology and robotics, rather than innovative models for delivering care to create evidence-based delivery systems. For this to be successful, payers would need to relax regulatory requirements and allow providers to use the dollars most effectively and efficiently without insurance companies dictating service delivery. An excellent example of this was in the recent SCI rehab study, a national study (Cahow, et. al. 2012) that looked at intensity and type of service provided to people with spinal cord injury. The most significant correlation between whether or not a patient successfully integrated back into the community was the amount of recreation therapy they received, which most payers currently don’t pay for. Also professional associations, which often dictate licensing of clinicians, would need to be willing to look at and reexamine whether a task or therapy truly requires a licensed therapist. This is especially true in brain injury rehabilitation when the patient’s medical needs diminish: Recreation therapists, job coaches and paraprofessionals become a more important part of the treatment plan.

Universal Outcomes and Patient Assessment Tool Critical to establishing post-acute bundled care payments, it will be absolutely necessary for providers and payers to agree on outcomes and work together to establish a fair payment for both parties. Using the five measures that were previously discussed, a payment model could be developed that focuses on incentivizing providers for returning patients home, getting them back to work, reducing the amount of assistance they need, reducing long-term medical costs and integrating them successfully into the community.

In addition, some agreement will be necessary in developing a standardized assessment tool so that we are clearly and accurately measuring patient progress and functional improvement.

Provides Some Risk to Both Payers and Providers If this model is to be successful and get buy-in from payers, providers must be willing to assume some risk for patient outcomes. For example, payers might incentivize providers if patients have no injury-related complications for a specified time period after discharge. In response, providers might guarantee outcomes by taking responsibility for injury-related or preventable complications during treatment and for a period following discharge. Again this would encourage providers to look at new ways to communicate and ensure that patients stay healthy, possibly using technology such as telemedicine, which is currently not paid for, or other unique strategies. An excellent example is a recent study (Gassaway, et. al., 2017) that created a focused curriculum for intensive peer support and found that not only did this improve patient’s self-efficacy in managing their own care needs, it substantially reduced re-hospitalization rates as well. This kind of innovation that begins to look at new ways of providing services will be critical in the future of value-based care.

While those payers that have long-term exposure to patients with catastrophic injury, such as Worker’s Compensation, Medicare and Medicaid, will be interested in long-term functional recovery and reduced costs, most commercial health plans have not embraced the benefit of this concept. This is most likely due to the fact that a high percentage of people who are catastrophically injured, especially brain injuries, who may be commercially insured at the time of injury, transition to government supported programs. In order for this model to be successful, all payers will need to embrace the concept of value and understand the long-term ROI associated with providing value-based care. At the same time, payers should hold providers accountable and expect a return on their investment.

Includes an Auditing Function Measuring outcomes in rehabilitation will always have some subjectivity and unfortunately a few unscrupulous providers have taken advantage. When I visit rehabilitation providers, while I notice that most staff have been adequately trained in the collection of standardized outcomes tools, very few organizations have implemented a scientifically sound interrater reliability or auditing function to verify data accuracy. If I was a payer, I would certainly want to know the integrity of what I am paying for, especially if I am paying more for favorable outcomes.

Reduces Regulatory Baggage If providers are financially at risk for producing outcomes, it only makes sense they be given some freedom in the way they treat patients. Currently, providers spend huge amounts of time in nontherapeutic time, such as documentation and compliance with regulatory requirements. The new system will need to balance giving providers flexibility yet insuring patient safety. In my opinion, a valuebased payment model would allow us, as providers, to provide the services we think will produce the best outcome, rather than those that are dictated by payment. It also would allow us to experiment with different service delivery models and build a body of evidence of the most optimal treatment intensities, services and locations.

Must Reduce Costs Perhaps the biggest challenge facing the implementation of valuebased payment is: “Will it reduce costs?” Given what we know about the shortcomings of current reimbursement as it relates to treatment of catastrophic injuries, will implementing a system that focuses on quality be less costly? One of the beauties of rehabilitation is that functional recovery is “the gift that keeps on giving,” achieving these outcomes not only produces a short-term cost benefit, but provides cost reductions throughout the patient’s lifetime.

Current cost benefit models often only take costs incurred during the rehabilitation process as it relates to functional improvement into consideration (e.g., FIM efficiency score). In a value-based model, long-term cost benefit will need to take into account future savings. For example, if a patient can return home, what was saved in institutional costs or if attendant care is reduced what would those savings be over a lifetime and if effective rehabilitation reduces the need for ongoing re-hospitalizations what value does that provide? To create incentive/disincentive based payment models, we will need to begin to think like healthcare economists rather than providers. It will be important to identify favorable outcomes and put relative monetary values on those outcomes. Finally, none of this will work unless we have a standardized reliable database that allows us to compare individual patient improvement with large numbers of similar patient outcomes to determine the value of his/her recovery.

Conclusion The field of rehabilitation is in an excellent position to create a service delivery model that benefits consumers, providers and payers. However, in order to accomplish this we will need to change some of the basic tenets that are embedded in our current system. This will require significant research and cooperation among payers and providers. The willingness by both parties to engage in pilot programs that minimize risk to both parties and allow us to refine the service delivery and reimbursement parameters of the model, will be necessary to move forward. This paradigm shift will mean challenging embedded antiquated concepts and replacing them with evidence-based concepts that may look nothing like the way rehabilitation is organized today.

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Although it is beyond the scope of this paper, one area that is rarely mentioned is social determinants of health and wellness and their influence on long-term outcomes. While we can successfully return someone to their community, if they do not have access to medical care and medications, affordable housing and transportation, attendant services, nutritional food and healthy social interactions, the investment made during rehabilitation is easily squandered. In addition, behavioral issues such as obesity, smoking, excessive use of alcohol and in the case of brain injury, safety, can have dramatic effects on quality of life as well as costs. If we are truly serious about valuebased payment models, we will need to take these factors into account. However, the big question is who pays for interventions and social structures that keep people healthy and protect outcomes achieved? As previously mentioned, for payers such as Medicaid, Medicare and Worker’s Compensation, these long-term savings would be appealing, but for short-term group health plans they would be viewed as both a financial burden and beyond the scope of most health insurance contracts. One of the biggest gaps in our health system is the lack of communication and cooperation between medical providers and community providers such as Public Health. Short of a single payer model, stronger linkages between medical and community-based services will be critical to the long-term success of value-based models. Just as we have an incredible opportunity, we have an even bigger challenge. Making these changes means attacking and questioning some of the most basic tenets of how we have delivered rehabilitation services for decades. These changes will require consumers, payers and providers to work together to benefit all stakeholders.

References Porter, M. (2010), What is Value in Healthcare? New England Journal of Medicine, 363, 2477-2481. Gassaway J, Jones ML, Sweatman M, Hong M, Anziano P, DeVault K. Effects of peer mentoring on self-efficacy and hospital readmission following inpatient rehabilitation of individuals with spinal cord injury: a randomized controlled trial. Archives Physical Medicine and Rehabilitation. 2017; 98:1526-1534. Final version published online: 26-Jul-2017. Ashley J, Ashley M, Masel, B, Randle K, Kreber L, Singh C, Harrington D & Griesbach G. (2018). The influence of post-acute rehabilitation length of stay on traumatic brain injury outcome: A retrospective exploratory study. Brain Injury, 10,1080. Cahow, C., Gassaway, J., Rider, C., Joyce, J. P., Bogenschutz, A., Edens, K. & Whiteneck, G. (2012). Relationship of therapeutic recreation inpatient rehabilitation interventions and patient characteristics to outcomes following spinal cord injury: The SCIRehab project. The journal of spinal cord medicine, 35(6), 547-564. Dobsan/Davanzo and Associates (2014). Assessment of Patient Outcomes of Rehabilitative Care Provided in Inpatient Rehabilitation Facilities and After Discharge. Submitted to ARA Research, Final Report, 13-127 DeJong, G. (2010). Bundling acute and post-acute payment: From a culture of compliance to a culture of innovation and best practice. Physical Therapy 90 (5) 658-662.

Author Bio Gary Ulicny, PhD, is president and CEO of GRU Health Care; and former president and CEO of Shepherd Center. Gary has published extensively in the area of rehabilitation and held adjunct appointments in the School of Medicine at the University of North Carolina-Chapel Hill and in the Department of Human Development at the University of Kansas. He was elected as a Fellow of the American Congress of Rehabilitation Medicine and received the Atlanta Business Chronicle’s Lifetime Achievement Award for contributions to healthcare.

Hopefully those that benefit the most are those who need our services.

Who are we and why choose us? We started Rehab Without Walls® NeuroSolutions more than 30 years ago as NeuroCare. We originally designed a program helping brain injury, spinal cord injury and stroke patients using real-life activities in the patient’s own environment. Today, we’re still removing walls, breaking down barriers and rebuilding lives. But we’re also connecting the NeuroCare continuum, providing expertise through our outpatient and residential services for adult and pediatric patients, in addition to our innovative home and community neurorehabilitation. • 866.734.2296 14 BRAIN INJURY professional

Highlight the quality services that you provide for people with acquired brain injury. You have quality practices in place to ensure optimal outcomes. Accreditation is the next step in growing your organization by demonstrating your person-centred focus, and your commitment to continuous quality improvement. CARF is a leading independent, nonprofit accreditor of health and human services, that accredits more than 1,121 brain injury programmes in the United States, Europe, the Middle East, New Zealand, and Canada. Our accreditation covers the continuum of services offered to individuals with ABI in a variety of treatment settings. About CARF: ■ Accredits programs interna�onally ■ Reviews business and clinical prac�ces ■ Guides person-centred, evidence-based prac�ces ■ Establishes quality performance improvement systems ■ Hosts training and educa�on on standards Benefits of CARF accredita�on: ■ Service excellence ■ Business improvement ■ Funding access ■ Compe��ve differen�a�on ■ Risk management ■ Posi�ve visibility ■ Accountability ■ Peer networking

Chris MacDonell

Snap the QR code or visit Programs/Medical for full program descriptions.

Managing Director, Medical Rehabilitation and International Aging Services

To learn more about CARF and how accreditation can help your organization. Call or email us today! (888) 281-6531

BRAIN INJURY professional 15

Principles-to-Practice: Payment Opportunities for Healthcare Providers Adam Seidner, MD, MPH, CIC

Background There are many healthcare payment models. Quality and outcome metrics play an important role in many of these payment models. Many healthcare payment models are creating incentives to implement preventative care strategies, prevent treatment complications, and avoid unnecessary treatment, hospitalizations, and readmissions. Certain payment methods can assist in balancing risk as well as incentives between payers and providers. The most traditional of the healthcare payment models is Fee-forService, which requires reimbursement for the service performed. A next step in these models is Pay-for-Coordination. This model involves payment for specified care coordination services, usually between certain types of providers. Coordinating care between providers can help create a single treatment plan and can help reduce redundant testing and treatments. In a Value-Based Payment Model physicians, hospitals, and other health care providers are reimbursed on measures including quality, efficiency, cost, and patient experience. Pay-for-performance (P4P) models are value-based. Healthcare providers are compensated if they meet certain agreed upon quality and efficiency metrics. Physician reimbursement depends on the quality of care they provide.

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Episode-of-Care Payment or bundled payments are single payments for services related to a condition that may involve multiple providers across delivery settings. Bundled payments reimburse healthcare providers for specific episodes of care such as a hospitalization. This healthcare payment model encourages efficiency and quality of care because there is only a set amount of money to pay for the entire episode of care. Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other healthcare providers, who voluntarily come together to provide coordinated high quality care to their patients. The goal of coordinated care is to ensure that patients receive the right care and avoid duplication of services. The ACO can help to deliver high-quality care, prevent medical errors, and develop efficient healthcare delivery. Realized savings are shared with the ACO and the providers. There are other payment models in healthcare such as capitation, global budget, and shared savings programs. The strengths and weakness of the various alternative payment models can be seen in FIGURE 1. Each payment method can be defined by the type or unit of payment. In addition, the model can reflect the financial risk between payers and providers. Important issues to be addressed while exploring, selecting, and implementing a novel payment structure for a practice include the ability to access, analyze, and apply your practice’s data. Physicians, hospitals, and health systems need to have a sound understanding of how their value-based care will be measured and rewarded.

Below are four areas to consider in raising awareness of and assisting healthcare providers’ to manage these new reimbursement opportunities.

FIGURE 1: Strengths Weakness of AlternativePayment PaymentModels Models(Miller (Miller 2017). Figure 1: Strengths andand Weakness of Alternative 2017)

Preparation Many rehabilitation providers have experienced challenges in receiving reimbursement for their services. Such challenges are one reason that providers should be reviewing and understanding variations in reimbursement contracts. Rehabilitation physicians and hospitals have a unique opportunity to consider adopting value-based payment models, including episodeof-care payments.

(Miller 2017) There are a number of things you need to know: Figure 2: Transition Period Outcomes are the desired benefits achieved by clinical management. Ideally, clinical interventions should minimize patient • Know how you are currently reimbursed and what contracts impairment, disability, and handicap. Outcome measurements you have with different payers. may be categorized as clinical, process, patient function, quality of • Know how many patients you have in the different health plans. life, and financial metrics. Clinical outcomes include accuracy of diagnosis, proper selection of diagnostics, and treatment adherence • Know what percentage of your revenue is coming from different to evidence-based guidelines. payers.

If you are you part of a healthcare system or an ACO, know how you are being measured, and know your quality, efficiency, and patient experience scores.

Perform a SWOT analysis, which is an assessment of the strength, weakness, opportunities and threats to the practice. Perform a detailed financial analysis and compare the average cost to deliver your services to what you are reimbursed for those services. Understanding your costs can assist you in your negotiation. In addition, this knowledge will help you identify areas you need to address to improve your practice. Remember, you are attempting to move from a volume-driven healthcare model to a value-driven healthcare model. You want to provide high quality and efficient care.

Measuring Success What outcome measures do you want to use to gauge your success? Measurements can come from quality, efficiency, cost, and patient experience. How do you or your organization measure quality? Are these measures consistent with nationally accepted measures? Be prepared to support why you have chosen the measurements on which you wish to be measured. Share meaningful data with the payer. Remember to demonstrate the efficiencies that reduce costs, and provide quality cost-effective healthcare. Monitor your hospitalization rates, types of tests your order, and treatments delivered. These can eventually be compared to benchmarks to establish you as an effective and quality healthcare provider. Trends in the variability of utilization or utilization rates for various diagnostic tests and treatments can also be measured to reveal your value.

Examples of process measurements include the timing, selection, and delivery of services. Utilization of durable medical equipment, pharmaceuticals, physical therapy, injections, radiologic images, surgery, and complications rates can be monitored and used as outcome measures. Rehabilitation physicians and hospitals have many screening tools and rating scales to measure patient outcomes. How are you using the Functional Independence Measure, Reintegration to Normal Living Index, Who Quality of Life-BREF, or the Numeric Pain Rating Scale? These and many other tools can help quantify patient improvement and ability. Medical providers can consider measuring their Return-to-Work and Stay-at-Work percentages.

Payers will look at different measurements, but they are simply an extension of these clinical tools. Payers monitor Total Claim Cost, which includes medical, indemnity, and other expenses. A payer will look at how much nursing or attendant care an individual requires. If the treating physician, through their care management, improves their patient’s functional status, less home care may be necessary, resulting in savings for the payer. The number of doctor visits per claim by diagnosis may be another payer-selected outcome measure.

Support Consider support from within and external to your organization when negotiating and developing contracts. Work with data analysts who can help you understand your data and outcomes. Be sure to have attorneys review and develop the contract language. Ensure that your contract includes clear reimbursement information on payment methodology.

BRAIN INJURY professional 17

Use available resources such as the American Medical Association’s National Managed Care Contract (NMCC) database, which is designed to help physicians analyze and negotiate contracts, and allows physicians and other healthcare providers to access updated statues and regulations on managed care contracting. Use the list of 96 questions that should be addressed when reviewing and negotiating contracts. Some of the questions involve defining payment methods, rate changes, and benefit plan incentives (Kehayes 2009).

Guidance The patient is required to be the central focus of the healthcare you deliver. A value-based payment or bundled payment model aligns your practice management and patient care paths with your patient’s needs and expectations. Value is created in caring for a patient’s medical condition, such as spinal cord or brain injury, over the period of care for that condition. Value is created when care is delivered through integrated services. Achieving value requires measuring the delivered outcomes and the cost to deliver those outcomes. Health plans will generally pay for covered services that are medically necessary. Understand the contract terms, such as “medically necessary” and “covered services.” The American Medical Association (AMA) defines “medically necessary” care as “health care services or products that a prudent physician would provide to

a patient for the purpose of preventing, diagnosing and treating an illness, injury, disease or symptom in a manner that is in accordance with generally accepted standards of medical practice.” Transitioning to a new payment model will take time. FIGURE 2 illustrates some of the steps in the payment model transformation process.

Conclusion Demonstrate your value and negotiate which outcomes may be appropriate for your clinical practice and patients. Once you have demonstrated your value, consider negotiating changes to the payer’s utilization review or prior authorization process. Changes to these processes can minimize interruptions to your workflow and make your day-to-day practice easier. Finally, know when to leave or end a contract. There will be times when you have to walk away to save your business from unachievable outcomes or inadequate reimbursement. References Heinemann, A. W.; “Putting outcome measurement in context: A rehabilitation psychology perspective” Rehabilitation Psychology, 50(1), 6-14, 2005. Miller, Howard; “Why Value-Based Payment Isn’t Working and How to Fix It: Creating a Patient-Centered Payment System to Support Higher-Quality, More Affordable Health Care” Center for Healthcare Quality and Payment Reform, 2017. Whiteneck GG; “The 44th annual John Stanley Coulter Lecture. Measuring what matters: key rehabilitation outcomes” Arch Phys Med Rehabil. Oct;75(10):1073-6, 1994.

FIGURE 5: Transitioning to Higher Performance and Affordable Prices

FIGURE 2: Transition Period (Miller 2017)

C. Defining and Paying Teams Author Bio

Under Fee-for-Service Payment, every physician, hospi-

order to participate in a Patient-Centered Payment system; indeed, it may actually be undesirable for them to do so, for two reasons:

Adam MD, provider MPH, has been Chief Medical Officer of ThespecifHartford Financial Services Group, Inc. since October 30, 2017. Dr. Seidner leads the tal,Seidner, and other is paid separately for each  AnPreviously, individual hospital, or Medical other healthcare Hartford Financial Services Group’s efforts in medicalPayments, innovation, howtraining and programs. Dr.physician, Seidner served as Global Director for ic service they render. Patient-Centered be a member of multiple Teams, so Travelers he was responsible for medical policy development, qualityprovider assurancewill andlikely improvement and worksite health promotion. Prior ever,Insurance, would bewhere defined based on patients and their that each Team can include the best individual provid-and to joining Travelers, he was Owner and Chief Health Advisor at Medical Meetinghouse. He is board certified by the American Board of Family Practice health conditions, rather than on providers and services. ers for the types of conditions and patients the Team the Under Board ofPatient-Centered Preventative Medicine: Occupational and Environmental Payments, a group of healthcareMedicine.


providers would need to work as a Team to successfully deliver all of the services the patient needed to achieve predefined outcomes for a particular condition in return BRAIN INJURY professional for a pre-defined payment amount.

is treating or managing. The best providers for a particular Team may not all work for the same organizational entity, and limiting Teams to providers who do work for one organization could result in poorer out-


The U.S. Consumer Products Safety Commission found more than 750 deaths and 25,000 hospitalizations in its 10-year study of the dangers of portable electric generators.


For the current guidelines: http://wedocs.unep. org/bitstream/handle/20.500.11822/8676/Select_ pollutants_guidelines.pdf?sequence=2


In an April 2017 carbon monoxide poisoning at a hotel in Niles, Michigan, several first responders had to be hospitalized because they were not wearing masks while they treated severely poisoned children. In a recent Detroit poisoning, the first responders did not have carbon monoxide detectors and also might have been poisoned. CO was not determined to be the cause for 20 to 30 minutes.

10. Source: “This paper was presented at the Proceedings of the 1st Annual Conference on


Environmental Toxicology, sponsored by the SysteMed Corporation and held m Fairborn, Ohio on 9, 10th and 11 September 1970.“

Experience You Can Trust in Brain Injury Law With over 30 years of experience in the area of head and brain injuries, nationally recognized Stark & Stark attorney Bruce H. Stern devotes himself to obtaining the compensation his injured clients deserve and to providing them with personal guidance to coordinate and promote the healing process.

Bruce H. Stern, Esq.


Gordon Johnson is a leading attorney, advocate and author on brain injury. He is a 1979 cum laude graduate of the University of Wisconsin law school and a journalism grad from Northwestern University. He has authored some of the most read web pages in brain injury. He is the Past Chair of the Traumatic Brain Injury Litigation Group, American Association of Justice. He was appointed by Wisconsin’s Governor to the state’s sub-agency, the TBI Task Force from 2002 – 2005. He is also the author of two novels on brain injury, Crashing Minds and Concussion is Forever. 1-800-53-LEGAL Follow Us: 993 Lenox Drive, Lawrenceville, NJ 08648

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We Put You First ...By improving the lives of individuals with a traumatic brain injury or other neurological impairment through residential and/or outpatient therapies. 5666 Clymer Road • Quakertown PA 18951 215-538-3488 • 22 BRAIN INJURY PROFESSIONAL

BRAIN INJURY professional 19

Patient-Centered Care: A Focus on Optimal Recovery Table 1

John Watts, Jr. Before becoming Paradigm’s CEO in 2017, I spent my career in healthcare, leading large payer organizations and advising several private equity backed healthcare companies. I held numerous management positions at Anthem, then the nation’s largest insurer, including President and CEO of Blue Cross Blue Shield of Georgia, President and CEO of Anthem National Accounts, and President and CEO of Anthem’s Commercial and Consumer Business. My years as an insurance executive in group health, where health plans help to access care and manage disease-related needs and interventions for individuals, gives me perspective on the immense value of focusing on meaningful clinical outcomes with financial accountability, as Paradigm does. Value-based care makes a tremendous difference in people’s lives, especially those with a complex injury like TBI. The highest priority must be to do the right things for patients at the right time to achieve the meaningful outcomes. Catastrophic injuries require a comprehensive approach that supports everyone involved, every step of the way. Paradigm’s model places the patient at the center of a dedicated case management team that is solely focused on an optimal medical recovery. Traumatic brain injury and other medically complex cases are difficult challenges for all stakeholders. To achieve greater results, these patients require care from those proficient in specialized skillsets and capabilities. A patient who recovers to the fullest extent possible from brain injury avoids a long tail of medical volatility and complications. Fewer complications translates into lower long-term medical care costs. As the total cost of a catastrophic claim usually reaches into millions of dollars, savings on a relative handful of claims are significant. This long-term financial exposure is far greater than the indemnity cost exposure, or even the highly expensive initial medical care costs during both the acute and rehabilitation period (the first 18-24 months).

In fact, Milliman, Inc., the nation’s leading actuarial consulting firm, studied more than 60,000 catastrophic cases, and found the industry distribution of spend during the lifetime of a catastrophic claim to be made up of 83% medical expenses vs. 17% indemnity expenses. (Milliman, 2008)

Acute Medical 18%

Indemnity 17%

Long Term Medical 65%

The impact of long-term claim expense is dramatic. To reduce FIGURE l1:eading actuarial a Milliman, Inc., the nation’s long-term costs, the best path is to Millman, Inc., the nation’s bring the claimant to the highest leading actuarial and clinical outcome during the acute consulting firm, 2008 and rehabilitation period.

Table 2

ACO as a Value Option The important distinguishing attribute of Accountable Care Organizations is the understanding that the ACO provider or provider entity is responsible for the healthcare quality, medical costs, and overall clinical results/outcomes for a defined population at a fixed price. Simply put, the focus is on financial accountability for the desired outcomes or results; hence, the ACO takes on financial risk. While most ACOs focus on population health management in group health, this value-based strategy can also play a role in improving and properly aligning the incentives of providers and stakeholders in the workers’ compensation system, which has been traditionally rooted in a transactional model dominated by utilization fee schedules, and jurisdictional management, discounting Annual Payment variations.


Paradigm’s perspective is that when the right medical interventions are applied to brain and other catastrophic injuries, better functional outcomes and significantly lowers costs are achievable.

$0 1




Reinsurance data – claims received traditiona

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Moreover, these same medical interventions can help course correct medical issues and complications during outbound years. These savings come in the form of reduced need for medical and support services, lower re-hospitalization rates and reduced pharmaceutical usage.

Short-term and long-term consequences of treatment decisions and care-management decisions related to given injury conditions

Clinical milestones and timelines typically required in order to achieve specific long-term outcomes

In an independent study, Milliman compared a random set of catastrophic cases, managed by Paradigm, to Milliman’s 100,000+ industry cases. (Milliman, 2013). In contrast to the industry cases, Paradigm uses an infrastructure called Systematic Care ManagementSM for managing catastrophic and complex cases. This approach involves constant oversight by a specialist physician, continual onsite case management by a highly skilled nurse case manager, and the infusion of case data from similar cases. The Paradigm managed cases, using the strategies outlined here, were shown to provide clinical outcomes at a rate five times better than the industry average. These same cases showed 40% lower costs during the life of the claim.

Identification of specific clinical, confounding risk factors with high-impact potential and early risk-stratification decision tools for proactive interventions and care planning.

Outcomes and Accountability Driven Culture The final requirement for managing volatility and uncertainty of catastrophic injuries is the appropriate mindset of the clinical teams involved. To obtain consistent achievement of effective outcomes, the care-management organization and its clinical members must possess and demonstrate a strong culture of accountability and reliability to drive actions and plans to help prevent risks, errors, and problems from occurring and/or their recurrence. The alignment of every stakeholder in the organization to the purpose of achieving effective functional outcomes contributes to successful care management.

Effective Functional Outcomes Being functional-outcome driven allows alignment of incentives across the care continuum rather than the ineffective transactional processes inherent in PPOs, utilization review, and other managedcare cost savers, which are exacerbated by the current fragmented healthcare delivery system.

Complications That Drive Expenses Several things are responsible for driving the high costs in catastrophic cases. First, there are numerous ongoing risks inherent in these types of cases. Second, there is a considerable amount of medical care involved. Third, there are complications due to the increased number of settings in which care takes place and the increased number of providers and specialists that deliver care. These factors increase the likelihood of errors that raise costs. Consider the high incidence of complications associated with a traumatic brain injury as an example of the risks inherent in catastrophic cases. The FIGURE 2 graph demonstrates the dramatic volatility that is inherent over time.

By proactively addressing and preventing failures in care delivery, failures of and/or lack of care coordination, and the waste associated with over-treatment and under-treatment, a focus on functional outcomes not only improves clinical results but also significantly reduces the inefficiencies inherent in our healthcare system.

Hallmarks of an ACO Approach A value-based care approach, essentially functioning as an ACO, Table 2 requires a system of effective communication, collaboration, clinical medicine, expertise, and innovation that integrates evidence-based care-standardization, robust data analytics, and a culture of continuous quality improvement.

Cost Volatility ath Sample of FIGURE 2: Cost Volatility Path of PFive Brain Injury Cases Over 14 Years Five Sample Brain Injury Cases Over 14 Years

Consultative medical specialists with extensive knowledge and subject-matter proficiency related to the precise diagnosis are essential to catastrophic injury care management.

Furthermore, it is important to have medical specialists and an who embrace the principles of functional restoration outcomes-oriented injury recovery process.

Better results come from giving attention to each of the three components for a strong recovery: biomedical, psychological, and social factors.

Annual Payment

Evidence-Based Medicine

Robust Data Analytics

Clinical analytic capabilities can guide the proactive delivery of helpful resources to the appropriate group of individuals at a crucial time, achieving lower rates of complications and better outcomes.

Frequency benchmarks of common and high-impact medical problems associated with these conditions















Claim Year Source: Reinsurance data for fCLAIM ive claims receiving traditional management YEAR (i.e., not Paradigm data care m anagement) Source: Reinsurance for five claims received traditional

management (ie., not Paradigm medical management)

BRAIN INJURY professional 21

FIGURE 3: Post Acute (24+ Months) Financial Volatility

Some of the more frequent complications driving increased medical need and costs include: skin breakdown, hydrocephalus, seizure disorder, spasticity/contracture, impulsivity, pneumonia, meningitis, chronic pain, and inability to live independently in the long term residential setting.

Each risk is case dependent and can greatly increase the ultimate costs of the case. FIGURE 3 shows how cases with poor management in the acute period can experience significant and expensive long term complications, even when the initial costs appear to have decreased. Note how the trajectories for Paradigm managed cases are quite different when it comes to cumulative Canoeing at Vinland’s main campus in Loretto, Minnesota medical expenses for all types of catastrophic injuries.

drug & alcohol treatment for adults with disabilities


Similar to an ACO, a value-based care approach allows problem management, mitigation of clinical risks, and avoidance of medical Millman, Inc., independent analysis comparing Paradigm cases to their complications to guarantee clinical outcomes for catastrophic injury proprietary database of similar workers’ compensation claims (2008). cases, resulting in highly satisfied patients, providers, and medical Milliman, Inc., independent analysis comparing Paradigm cost savings over time. Vinland Center provides drug and alcohol treatment for adults with

workers’ cBio ompensation claims (2009). Author cognitive disabilities, including traumatic brain injury, fetal alcohol Paying all medical expenses until the outcome is achieved reduces John Watts, Jr. is the Chief Executive Officerall of Paradigm Outcomes. spectrum disorder and learning disabilities. We make possible uncertainty for payers, enabling the clinical team to focus on In this role, he oversees Paradigm’s nationwide organization and the most effective treatment plan for theaccommodations injured worker, rather for cognitive deficits and all business functions of theindividual company and itslearning subsidiaries. styles. He is than individual medical costs and volume of services. Ultimately, Located in Loretto, everyone benefits from the best outcomes. References Milliman, Inc., 2013

responsible for the company’s strategic planning, partnerships and

Minnesota justJohn’s 20 expertise miles includes west of Minneapolis. future— growth. building, growing, and leading large health plan organizations, strategy development, team building, and leadership development. John joined the Board of Paradigm Outcomes in 2016 and became Paradigm’s CEO in 2017. John brings a robust career in healthcare, leading large payer organizations and advising several private equity backed healthcare companies.

(763)479-3555 •

Milliman, Inc., 2008




Restore Neurobehavioral Center is a residential, post acute healthcare organization dedicated exclusively to serving adults with acquired brain injury who also present with moderate to severe behavioral problems. Services range from intensive inpatient neuro-rehabilitation and transitional community re-entry services to long term supported living services. Restore Neurobehavioral Center, located in a suburb north of Atlanta, is the site of our inpatient post acute neuro-rehabilitation program as well as one of our supported living sites. We operate two other community living sites, Restore-Lilburn (GA) and Restore-Ragland (AL). 800-437-7972 ext 8251 22 BRAIN INJURY professional



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nderstanding rain njury

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BRAIN INJURY INJURY professional professional 27 19 BRAIN

Neuro-Net and the Seamless Future for Brain and Spinal Cord Injury Rehabilitation Ann Perkins, MA • Debra Braunling-McMorrow, PhD • Deborah Doherty, MD • Ben Dirlikov, MA Irwin Altman, PhD, MBA

Introduction In the face of an unsettled health policy landscape, predicting the precise direction of healthcare reform is challenging. Despite this uncertainty, it is probable that some form of value-based care will prevail. (Choo, 2018) As part of an effective transition to pay-for-performance care, and as an essential component in healthcare reform itself, integrated care delivery models will play a critical role. This evolution toward more coordinated care, focusing on obtaining the right services at the right time in the right setting, will be the requisite approach to replace current, more fragmented systems of care. (Lea, 2015) Toward this objective, Neuro-Net was launched in 2014 as an integrated continuum-of-care model with a network of providers working together to improve long-term outcomes and quality of life for persons with brain injury (BI) and/or spinal cord injury (SCI). These providers include the Rehabilitation Center at Santa Clara Valley Medical Center, Care Meridian, Learning Services and Rehab Without Walls. Specifically, the program was developed to provide a more effective, efficient and convenient pathway of care for persons with catastrophic injuries by coordinating care from the time of injury to one year following discharge. (FIGURE 1)

For some, brain and/or spinal cord injury can be a chronic condition. Beyond the initial event, these injuries sometimes mark the beginning of a lifelong condition that involves multiple organ systems and may be both disease causative and disease accelerative (Masel, et. al., 2010). Beyond the human toll, lifetime direct and indirect medical costs are estimated at $1.9 million per person for severe traumatic brain injury (Coronado, et. al., 2012) and depending upon severity, from $1.07 to $4.5 million for persons with spinal cord injury. (NSCISC, 2012) Neuro-Net is a coordinated disease management approach intended to improve outcomes and reduce costs. In a 2012 Cochrane Review of multiple studies, Early Supportive Discharge (ESD) for stroke patients was associated with shorter hospital stays and increased independence at the time of discharge and at six month follow-up, with the majority showing measurable cost savings. (Fearon, et. al., 2012) In addition, the Johns Hopkins Guided Care Nurse (GCN) model for chronically ill patients resulted in reduced hospital stays as well as fewer skilled nursing facility days, emergency room visits and home health care episodes, resulting in significant net cost savings per patient. (Boult, et. al., 2011).

FIGURE 1 Restoring Hope

r Care

TRAUMA Patient suffers catastrophic illness or injury — taken to acute care hospital and provided with high level trauma resources A Neuro-Net Case Manager coordinates every stage of recovery

HOME REHAB/ TRANSITION Higher functioning patient returns home, but still in need of improving basic functional skills to regain independence

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Patient can enter collaborative at any point in time.

POST-ACUTE CARE Patient moved to post acute care facility and receives nursing and initial rehab — patient still in need of 24/7 care and medical management

ACUTE REHAB Patient with highly limited mobility enters acute rehab facility with expert equipment and staffing

REHAB Patient no longer requires nursing, is higher functioning, but still in need of intense rehab and functional skills to participate in practical daily activities

A Focus on Care Coordination and Management The Neuro-Net continuum of care platform rests on the dual pillars of clinical integration of services and the consistent delivery of meaningful outcomes. The clinical integration component of the program is facilitated by a case manager with specialization in the areas of brain injury and spinal cord injury. The role of the case manager is to provide an initial assessment and plan of care and to ensure that the patient receives appropriate and timely treatment. The case manager also serves as the primary liaison with the patient, family, healthcare providers and payers. The case manager remains an ongoing resource to the patient and family throughout the first year postinjury. To facilitate the highest possible degree of access, this benefit is available at no cost. As part of the collaborative model, all partners share electronic documentation and outcome data management systems. Each partner participates in a bi-monthly clinical conference call that includes a BI-boarded physiatrist and a SCI-boarded physiatrist. During this call, patient progress and the appropriate timing for transition from one level of care to another are discussed. While multi-disciplinary rehabilitation rounds are virtually universal, Neuro-Net takes the process one step further by having clinical representatives from all levels of the continuum of care attend. This increased level of coordination creates more effective care transitions and better prepares the patient and family for the next step. In many systems, obtaining feedback regarding patients who move to a different service provider has generally been anecdotal at best. To date, Neuro-Net has provided the participating partners with factual and timely information throughout the continuum of care. By forging ongoing relationships among providers at each level of care, Neuro-Net partners are able to launch numerous quality improvement initiatives throughout the continuum. This achievement is the result of a better understanding of the resources and patient experiences within the various care settings. Some examples include determining optimal timing for prescribing durable medical equipment (DME) and pharmacy items to assure appropriate access, therapy evaluations at transition points, reducing the chances of negatively impacting the patient’s progress during transitions and communications across the continuum that include the improved hand-off of critical information and reducing the chances of negatively impacting the patient’s progress during transitions. In the continuing effort to better meet patient and family needs, Neuro-Net sponsors a patient Advisory Board that offers advice to the program’s leadership on how the initiative can best be organized, executed, and validated based on patient-centered criteria. Although most members attend in person, a WebEx option is available as needed. All Neuro-Net enrollees can attend Advisory Board meetings to provide counsel on program issues and enhancements.

Research The Neuro-Net program collects outcome data across providers to provide a quantitative method to assess efficacy as well as diagnostic-specific changes throughout the continuum. In the past year, the program has moved to a cloud-based data collection system that automatically updates a central research database housed in the Rehabilitation Research Center (RRC) at Santa Clara Valley Medical Center (SCVMC). Quantitative assessments in Neuro-Net include the Functional Independence Measure (FIM), Mayo-Portland Adaptability Inventory-4 (MPAI-4), Supervision Rating Scale (SRS) and Satisfaction with Life Scale (SWL). Preliminary analysis of the functional outcomes reveals significant improvements across providers.

BRAIN INJURY professional 25

Wilcoxon Rank-Sum Tests reveal significant FIM improvements from admission to discharge at SCVMC (Z = -4.4, p <.001) and CareMeridian (Z = -2.9, p =.003). Rehab Without Walls showed significant improvements as measured by the MPAI-4 (Z = -2.7, p =.008). Learning Services showed improvements on the MPAI-4 and SWL in all of the Neuro-Net patients treated at their center. These preliminary results provide evidence of the effectiveness and feasibility of the program. The Neuro-Net partnership will expand the analysis to investigate changes related to diagnosis balanced, site-specific control groups.

Fine tune assessments: Explore additional measures to capture meaningful changes at various stages of recovery within the Neuro-Net continuum of care.

Identify responders: Analyze data to identify subsets of patients who may benefit most (or least) from the program’s coordinated network of clinical care providers.

Future Directions

Improve the transition process from one partner (clinical level of care) to the next: Assess optimal patient hand-offs to maximize patient progress, minimize duplication of services and length of stay and ensure that DME necessary for a smooth transition home is ordered at the appropriate time.

Bring more people to the table: Invite payer (private insurance and government programs) and community representatives to the Advisory Board meetings to encourage feedback and innovation regarding Neuro-Net processes.

Align with healthcare systems and health insurance companies to offer their members access to Neuro-Net’s coordinated services.

Each clinical partner in the Neuro-Net system specializes in managing different, yet overlapping stages of recovery after catastrophic neurological injury. All partners share an exceptional commitment to achieving improved outcomes, greater efficiency/ reduced costs and increased patient and family satisfaction. As noted above, ongoing data collection and analysis across multiple providers are critical to optimize the services provided


Moving forward, the Neuro-Net program will continue to pursue the following goals:

1. Boult, C., Reider L., Leff B., Frick KD., Boyd CM., Wolff JL., Frey K, Karm L., Wegener ST., Mroz T., Scharfstein DO.The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med, 171(5):460-466, 2011.

2. Choo, M. The Future of Value-Based Care in Workers’ Compensation – Part 1 WorkCompWire, January 2, 2018.

Accurately assess injury severity: Identify best methods/ measurement tools to stratify severity of injury and complexity of illness across all persons served by Neuro-Net to appropriately cohort patients in order to allow comparison with standard non-Neuro-Net care. Assess the efficacy of the Neuro-Net program: Evaluate outcomes, length-of-stay, cost-of-care, patient satisfaction, post-discharge emergency room visits and re-hospitalization rates for Neuro-Net patients compared to non-Neuro-Net patients overall and across diagnosis-specific groups.

3. Coronado, V.G., Faul, M., McGuire, L.C., Sugerman, D., Pearson, W.S. The Epidemiology and Prevention of TBI., 2012. 4. Lea, R. Modifying Post-Reform Care Delivery Models for Workers Compensation. Brain Injury Professionals, 12(2), 2015. 5. Fearon, P. & Langhorne, P. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Syst Rev. Sep 12;9, 2012. 6. Masel, B. & DeWitt, D. Traumatic Brain Injury: A Disease Process, Not an Event. Journal of Neurotrauma, 27(8), 1529-1540, 2010. 7. National Spinal Cord Injury Statistical Center (NSCISC). Spinal cord facts and figures at a glance., Birmingham, Al. 2012.

Author Bios Ann Perkins, MA, received her Bachelors Degree in Psychology at the University of California Santa Cruz. She graduated with Honors from Santa Clara University with a Masters Degree in Counseling Psychology. She has worked in many facets of Rehabilitation, including Acute Inpatient Rehabilitation, Long Term Disability Management, Catastrophic Case Management and Vocational Rehabilitation. Currently Ann is the Director of Rehabilitation Relations at Santa Clara Valley Medical Center, a position she has held for 13 years. In her position at Santa Clara Valley, Ann is responsible for designing and implementing the outreach program for the Rehabilitation Center, provider relations, as well as strategic business planning. Irwin M. Altman, PhD, MBA, is the National Director of Acquired Brain Injury (ABI) Residential Services of Rehab Without Walls NeuroSolutions, a post acute, community-based neurorehabilitation program in 14 states and Ontario, Canada. Dr. Altman is a Clinical Neuropsychologist with more than 30years in developing and running brain injury and spinal cord injury rehabilitation programs for adults, adolescents and children. He is in a leadership role in Rehab Without Walls NeuroSolutions outcome management. His work has been published in various peer review journals and has presented at numerous national and local meetings. Dr. Altman serves on several boards including the Sports Concussion Coalition of Arizona and the Rehabilitation Insurance Networking Group of Arizona. Deborah Doherty, MD, is a Physical Medicine & Rehabilitation (PM&R) board-certified physician specializing in the medical care and rehabilitation of individuals who have sustained brain injuries ranging from coma to concussion. With more than 25 years as the Medical Director of Brain Injury Programs in acute rehabilitation and long-term acute care (LTAC), Dr. Doherty now is corporate Director of Brain Injury Rehabilitation Programming for CareMeridian, LLC. She has been Rehabilitation Medical Director for CareMeridian’s Marin County facility since 2001. Dr. Doherty lectures widely on topics related to brain injury, and she is particularly interested in disorders of consciousness. Debra Braunling-McMorrow , PhD, is the President and CEO of Learning Services, a national provider of services for persons with brain injury. She has served as Vice President of Business Development and Outcomes and Vice President of Quality Assurance for a national rehabilitation provider. In addition, she led operations for the Center for Comprehensive Services, one of the first post acute brain injury rehabilitation programs in the country. She serves on the board of the North American Brain Injury Society and is the recipient of the 2007 NABIS Clinical Service Award. Ben Dirlikov, MA Biopsychology, is the Director for the Rehabilitation Research Center (RRC) at Santa Clara Valley Medical Center. He has published and presented at national and international conferences, and received a Young Investigator Award from the Neurobiology of Disease in Children’s Conference. He brings this perspective and passion for patient centered research to the RRC, which aims to improve patient care by investigating innovative treatments, identifying and promoting protective factors, and understanding the continuum of care for individuals with BI, SCI and stroke.

26 BRAIN INJURY professional

Conclusion Concussion management is an ever-evolving area of treatment designed to better protect athletes from suffering the lingering and potentially permanent effects and symptoms of a concussion and premature return to play. Remember, treating concussions, particularly those that do not resolve quickly, is a complex and dynamic process. It is important to stay up to date on the literature, consensus statements, updated organizational/institutional protocols and requirements, and state laws. Maintain adequate and complete records. Educate the athlete, the parents, if applicable, coaches, etc. to ensure everyone is doing their role to protect the athlete, is aware of the risks and dangers, and can assist in providing the best care for the safe return to play of the concussed athlete.


Specializing solely in post-acute neuro rehab since 1982







7. 8. 9. 10.


12. 13. 14.

Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the 1st International Symposium on Concussion in Sport, Vienna 2011. Clin J Sport Med 2002:12:6-11. Aubry M, Cantu R, Dvorak J, et al. Summary and agreement statement of the 1st International Symposium on Concussion in Sport, Vienna 2011. Clin J Sport Med 2002:12:6-11. McCrory P, Johnston K, Meeuwisse W, et al. Summary and agreement statement of the 2nd International Symposium on Concussion in Sport, Prague 2004. Br J Sports Med 2005; 39:196-204; McCrory P, Meeuwisse Q, Johnston K, et al. Consensus statement on concussion in sport: the third international conference on concussion in sport held in Zurich, November 2008. Phys Sportsmed 2009;37:141-59; McCrory P, Meeuwisse WH, Aubry M, et al., Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258.\ Guskiewicz, K, Bruce, S, Cantu, R, et al., National Athletic Trainers’ Association Position Statement: Management of Sport-Related Concussion. Journal of Athletic Training 2004;39(3)280-297. Broglio, S, Cantu, R, Gioia, G et al., National Athletic Trainers’ Association Position Statement: Management of Sport Concussion. Journal of Athletic Training 2014:49(2):000-000. Giza, C, Kutcher, J, Ashwal, S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports, American Academy of Neurology. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258 Giza, C, Kutcher, J, Ashwal, S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports, American Academy of Neurology. Giza, C, Kutcher, J, Ashwal, S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports, American Academy of Neurology. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258 at Table 1. McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013;47:250-258 at Table 1; Giza, C, Kutcher, J, Ashwal, S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports, American Academy of Neurology.

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expert interview

with Dr. Marc Duerden

Marc Duerden, MD, FAAPMR, CIME

Marc Duerden, MD, FAAPMR, CIME, works for National Government Services as a Medicare contractor to develop and adjudicate the application of Medicare policies. He is a Physical Medicine and Rehabilitation physician who graduated from Purdue University with a BS in Chemistry, and Indiana University with an MD. He graduated from the premier residency training program at Northwestern University Rehabilitation Institute of Chicago, now Shirley Ryan Ability Lab, in Physical Medicine and Rehabilitation. He was then recruited to join the faculty at the new Indiana University School of Medicine residency training program and worked with the physician group at Rehabilitation Associates of Indiana for about 20 years. He is board certified in Physical Medicine and Rehabilitation, Spinal Cord Injury Medicine, Independent Medical Examinations, and Disability Analysis. He is a part-time solo-practitioner.

Q. How do you measure value in medical services for TBI? A. The value of medical services for TBI is based on what is reasonable and necessary. I have always seen reasonable as items that are safe effective, appropriate, non-experimental, and cost effective. Medically necessary means what is needed to treat, diagnose, or prevent any specific injury or illness based on evidencebased medicine. Evidence-based medicine indicates three things: 1. Data and journal articles citing what can be seen and measured as statistically significant 2. Clinical judgement of the treating provider and the profession as whole, including published studies, journals, association guidelines, general acceptance by the medical community (standard of practice), and medical opinions from consultations 3. Patient Values. If a patient is not willing to take a specific treatment, it would not be considered “evidence-based medicine” to offer a treatment contradicted by the patient’s values. For example, a physician would not provide blood products to treat anemia to a Jehovah’s Witness who refuses blood products. Q. How do you see the parameters around rehabilitation for brain injury changing? A. It’s time to move from a service model to a recovery model. In a service model, the care is provided in a linear course or continuum of care consisting of services, delivery systems and venues -- ER, acute care, long term acute care, acute rehab, daycare, home health, outpatient care, etc. We should define the rehabilitation treatment by stages of recovery. For example, the treatment of individual with a TBI diagnosed as a level Rancho 4, doesn’t necessarily indicate or require a specific place of service. What is needed is a place of service designed to the individual’s recovery. Why not determine treatment based on what a patient actually needs? Maybe a patient needs to go to skilled nursing and then to acute rehab. We should not be bound by the limiting linear approach to care typically found in the service model. The solution is to shift the paradigm from a place-of-service model to a recovery model. In this scenario, service providers must show they are actually doing what they say they are: providing value and benefit to the patient, rather than simply providing 3 hours of service a day in an acute inpatient rehabilitation unit.

28 BRAIN INJURY professional

Q. How do current chronic care models apply to brain injury patients? A. The chronic care model developed for persistent chronic illnesses that have a natural history of decline is inadequate for catastrophic TBI, SCI, or cerebral vascular accidents. These traumatic brain injuries or acquired brain injuries are not progressive after the acute period. Brain injury management requires a different approach and other metrics. For example, in congestive heart failure, you expect progressive decline of cardiac function. The typical metric to assess good management is to show a reduced hospital readmission rate. Or in dementia, you know you’re going to have a steady decline and treatment paradigms and metrics are used to follow that cognitive decline. However, with TBI or stroke, patients don’t necessarily get progressively worse. These conditions should become static. We must develop a chronic care model that focusses on reducing complications and secondary challenges from TBI. I envision interdisciplinary teams that improve brain injury chronic care management beginning with a transformation and advances in the research and clinical knowledge we currently have on TBI to establish an outlook on the natural history of the disorder. There needs to be clinical teams and clinical practice guidelines to include more case managers. A lot of what physicians are doing now is case management -- social work -- that takes time away from directly delivering medical care. This mismatch of resources increases physician/provider stress and burnout. This problem is easily rectified by placing a case manager in the system and creating an interactive team. In no way does this diminish the physician’s central leadership role. The physician leads the team, receiving communication from caregivers, therapists, specialists. The case manager is a voice in the system that helps in overall management of the patient and reducing the administrative burden on physicians. Q. What do you see as the future of rehab care for TBI and beyond, including stroke? A. The future must address four areas: 1. Prevention of illness and injury More science must be applied to what really are the most valuable preventive measures. A helmet may not be the only or best way to prevent brain injury. Efforts have begun to develop guidelines for management of blood pressure control to reduce risk of stroke. We are all aware of steps to reduce impacts during recreational and professional sports, including requiring helmets and reducing head-to-head contact.


Development of data analytics to study treatments and outcomes I am astonished that even in current discussions, there is lack of consensus about something as basic as an agreedupon definition for the terms we use in brain injury. It is not infrequent in the TBI literature to see varied use and definitions for terms, such as “cognitive rehabilitation,” “cognitive training,” and “cognitive stimulation.” More fundamentally, the same Neurorehabilitation confusion applies to how medicine defines “mild,” “moderate,” and “severe” TBI. Terms need to be clarified, as do treatment protocols and outcomes measures.

Early thrombolytic therapy with Tissue Plasminogen Activators (TPA) has greatly benefited acute stroke patients, but there is yet nothing available for treating early hemorrhagic stroke management.

Concussion, Mild, Moderate and Severe Brain Injury

4. Determine appropriate chronic care models and continuum of Complex Cases. Outcomes that work. care models

Neurobehavioral Rehabilitation and Supported Living


Creation of rapid analysis and early intervention to reduce secondary effectsLiving of injury Supported Right now the immediate reaction to a traumatic brain injury or stroke is elementary. With a sports injury, if the player is Outpatient, Community woozy on the field,Home we take and the player off the field Services and we may order a head CT, which is of little value. There is no tool, test, or examination to show severity of theServices brain injury right at the Assessment andtheEvaluation beginning, when there is the greatest opportunity to reverse neurotoxic effects. Stroke also requires early intervention.

An appropriate continuum of care can manage these patients to prevent secondary complications and injuries, including UTI and aspirational pneumonia. We need better guidelines and algorithms developed by the profession. If the profession doesn’t lead the effort, payers will secondarily development them and their motive is not the same as the care of the individual. Of course, the government is the biggest payer.

In my little corner of the healthcare world, writing local coverage determinations, I have begun addressing some of these issues. I want to use medical and paramedical groups such as the AMA, Academy of PM&R, Speech and Hearing Association, Physical Therapy Association, and EMS associations to come up with the brain injury guidelines.

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Michael Choo, MD is Paradigm Outcomes’ Chief Medical Officer. He maintains relationships with Paradigm’s network of consulting physicians and centers of excellence, and is responsible for enhancing clinical operations and leading research and development. He also teaches emergency medicine, internal medicine, and family practice residents at Wright State University’s Boonshoft School of Medicine.

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Coma and Disorders of Consciousness

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Traumatic Brain Injury – Rehabilitation, Treatment, and Case Management

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