Major Issues in Post-acute TBI Rehabilitation

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BRAIN INJURY professional vol. 15 issue 1

Major Issues in Post-acute TBI



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vol. 15 issue 1



Guest Editor’s Message


Editorial Advisory Board


BIP Expert Interview


Product Update


New Books of Interest



Post-Acute Rehabilitation Edifying Efficacy Evidence


What Should Comprehensive Neurorehabilitation in a Transitional Residential Rehabilitation Program Look Like?


Gary S. Seale, PhD • Brent E. Masel, MD


Post-acute Transitional Residential Rehabilitation and Changes in Decision-Making Capacity Margaret Kroese, MSSW • Martin J. Waalkes, PhD, ABPP, CBIST


What Families, Clinicians and Payors Need to Know About Transitional Rehabilitation Gary S. Seale, PhD • Nicholas J. Cioe, PhD • Susan H. Connors


Money, Management and Mergers: The Business Aspects of Post-acute ABI Neurorehabilitation Dexter W. Braff, MBA, MS, BA • Ted Jordan, MBA, BS • Nancy Weisling, BS

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

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 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: 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

guest editors

It is with great pleasure that we introduce this special issue on post-acute rehabilitation for Brain Injury Professional. We hope that readers find the articles both informative and thought provoking. We have tried to assemble an array of topics that address some of what we perceive as the major issues and interests germane to post-acute rehabilitation with particular emphasis on transitional residential rehabilitation services.


The article by Zasler and Ashley entitled ”Post-acute rehabilitation: Edifying efficacy evidence” examines the current literature supporting the clinical efficacy as well as cost benefit of such services. Our hope with this article is to also encourage professionals to advocate for access to these services given the existing evidence as well as to expand research efforts to add to the existing foundational tenants for such services. In their article on “What should comprehensive neurorehabilitation in a transitional residential rehabilitation program look like?”, Drs. Seale and Masel discuss historical aspects of the TBI continuum of care and recommended components of a comprehensive interdisciplinary transitional residential treatment program. The role of various “players” is nicely reviewed in this context. They also emphasized the role of discharge planning follow-up and need for outcomes reporting. Kroese and Waalkes address issues of decision-making capacity in their article “Post-acute transitional residential rehabilitation and changes in decision-making capacity.” This is a very important topic that often does not receive appropriate attention by health care professionals involved with TBI care. The authors discuss the evolution of decision-making capacity in the context of neurorecovery and neurorehabilitation. They also provide a nice overview of capacity determination and the types of abilities germane to same. They bring up important points regarding the implications of limited decision-making capacity and attempts to optimize the involvement of the person with TBI in appropriate decision-making tasks. The article’s main focus is how we might go about treating patients with changing levels of capacity and the ethical and programmatic challenges involved in same within the post-acute setting. We think all readers will find this information helpful and of assistance in dealing with these clinical and ethical challenges.

Mark J. Ashley, ScD, CCC-SLP, CCM, CBIST

In the article entitled, “What families, clinicians and payers need to know about transitional rehabilitation”, Seale, Cioe and Connors clarify the scope of transitional residential rehabilitation and how it differs from other treatments. A major emphasis of this article is the challenges that are faced by those of us in the trenches to advocate for payment for such services given the lack of familiarity by many payers with this level of service as well as with the evidence of transitional rehabilitation (TR) efficacy. The authors also provide some nice insights into how increased payor understanding of TR services for persons with TBI results in a panoply of benefits for not just the patient, but the payor as well. Taking a somewhat different focus, the article by Braff, Jordan and Weisling, “Money, management and mergers: The business aspects of post-acute ABI neurorehabilitation” provides readers with some “out of the box” perspectives on the business of post-acute ABI/TBI care. These authors provide a very insightful examination of some of the elements that those of us who are involved in ownership and/or management of such programs need to be well aware of. In that context, issues of quality of care, profit, revenues and growth including revenues cycle management, expenses and technology deployment are discussed. There is also commentary on the pros and cons of owning the real estate, the complexities of growth in the current health care market, and the challenges involved with risks of running such businesses. Lastly, given Dr. Ashley’s long-standing work in the field and, in particular, his work in post-acute rehabilitation care, I (Dr. Zasler) thought it would be intriguing to interview my colleague and coeditor for this issue. I have tried to tap Dr. Ashley’s brain regarding a number of different issues in the context of how the field of post-acute TBI care has evolved, what some of the challenges are contextually in terms of service provision and program viability, and the importance of continuing to advocate for such services and provide evidence through good research for same. We both hope this issue of Brain Injury Professional expands the reader’s knowledge regarding the subject matter and provides some useful insights into how to move this piece of the brain injury continuum of care forward for our patient’s, their families, and all invested parties. Nathan Zasler, MD Mark Ashley, ScD

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In Memoriam The founder of the North American Brain Injury Society, Dr. Robert (Bob) Voogt, passed away on February 13, 2018, in Virginia Beach, Virginia. Bob was a true pioneer in the brain injury field. Recognizing the need for an organization devoted specifically to addressing the needs of multidisciplinary brain injury professionals, Bob was the driving force behind NABIS and served as its first Chairperson. He believed that whether in the area of clinical care, research, policy or advocacy, the organization he founded should stand behind the premise that advances in science and practices based on application of the scientific evidence would ultimately provide the best outcomes for those with brain injuries and their families. It is not an understatement to say that the brain injury community worldwide owes Bob a tremendous debt of gratitude. Robert D. Voogt 1949 - 2018

In addition to serving as Chairperson of NABIS, he also served the brain injury community as Chairperson of both the International Brain Injury Association and the Brain Injury Association of America. He was an internationally renowned advocate for persons with brain injury, lecturing and testifying at the federal and state level, and was honored to have been invited to an audience with the Pope in Vatican City. In addition to his advocacy efforts, he built and managed residential neurological rehabilitation facilities in Louisiana and in Virginia. To honor this extraordinary man, the leadership of NABIS will be establishing a new Robert Voogt Founders Award shortly after the 2018 annual NABIS conference in Houston. Remembrances of Bob may be posted on the NABIS website,

editorial advisory board Dear BIP readers, It is with great pleasure that we introduce our new Editorial Advisory Board (EAB) for Brain Injury Professional to our international readership. We have made every effort to strive for international representation in our EAB based on country of origin as well as have an admixture of disciplines to facilitate the basic interdisciplinary premise of this publication. We have also attempted to try and encourage junior clinicians as well as those with established reputations in the field to participate in our EAB. We look forward to working with each of these clinicians and to their contributions to BIP. Debra Braunling-McMorrow, PhD - Co-editor Nathan Zasler, MD - Co-editor Juan Arango-Lasprilla, PhD - Associate Editor

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 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

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Post-Acute Rehabilitation: Edifying Efficacy Evidence Nathan D. Zasler, MD, DABPM&R, FAAPM&R, FACRM, BIM-C, FIAIME, DAIPM, CBIST Mark J. Ashley, ScD, CCC-SLP, CCM, CBIST

Introduction The role and benefits of post-acute rehabilitation (PAR) are often underappreciated by payors and clinicians, particularly, how appropriate services provide at the right time and intensity can contribute to improved neurological outcome. There is a lack of understanding regarding the benefits of continued neurorehabilitation in the PAR setting which perpetuates reduced funding support for PAR which results in decreased access to medically necessary services. It is the opinion of the authors that clinical care should be driven by good science and the cost/benefit of the intervention rather than by payor-mandated cost controls. We hope this review helps to educate all parties involved with traumatic brain injury (TBI) care to gain insights into post-acute care issues and efficacy.

Challenges in PAR outcomes research Challenges exist in assessing PAR outcomes and include the following: 1) heterogeneity of the patient population; 2) a lack of standardized paradigms for assessment and treatment for most conditions for which PAR is provided; and 3) substantive differences in treatment settings (i.e. location, staff specialization level, intensity of treatment, length of stay and nature of treatment) (Glenn, et al, 2005). Recent research on multidisciplinary PAR efficacy after more significant TBI noted some of the limitations of the current literature; however, it should be noted that the study focused on cognitive rehabilitation and social functioning and no other areas of outcome (Brasure, et al, 2012). Further research should be encouraged that emphasizes the use of standardized measurement of patient characteristics as well as outcomes (Malec & Basford, 1996).

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Moving forward, research must also better examine how the timing, duration, and treatment intensity of specific therapies and/ or combination therapies, whether traditional, pharmacologic, neuro-modulatory or other possibilities, might impact recovery and outcome durability.

Basic science literature supporting PAR The brain has a lifelong capacity for plasticity which is driven by a variety of different factors. In fact, plasticity is the brain’s normal state. Environmental enrichment (EE) has been reliably shown to drive plasticity at molecular and morphological levels (Alwis, 2014; Wang, 2016). As such, EE serves as a potential basis of adaptive changes in neuronal function, and, ultimately, behavior in all animals, brain injured or not. EE typically involves providing multisensory stimulation at levels much greater than those that occur under circumstances such as those provided in home care and outpatient periodic therapies. Two paradigms exist for providing EE. Specific EE focuses on one specific area of function such as cognitive or motor function. Generic EE, however, occurs when the entire environment is nonselectively enriched. Animal studies demonstrate improvement in intellectual functioning, behavioral modulation, and certain motor behaviors. Adverse effects may occur that have yet to be fully delineated (for example, overstimulation in the environment may produce increased agitation). Adverse effects may also constitute maladaptive plasticity. PAR provides for a controlled application of EE together with structured behavioral paradigms that combine to promote adaptive and discourage maladaptive plasticity. Significant data supports changes in neuronal function involving subcortical structures such as the hippocampus.

However, further research assessing optimal parameters for same remain lacking (Wogensen et al, 2015). Lack of EE, whether from limitations in participation, ability, or funding support may play a part in the functional decline observed in a significant percentage of persons with moderate to severe TBI. Frasca and colleagues (2013) published a scoping review of literature on EE in animals and humans as well as post discharge experiences related to barriers to recovery. Their findings provide support for attempting prophylaxis against long-term decline following TBI through continued and optimal EE. There is much to be learned about specific mechanisms of EE in neurorehabilitation; however, there is certainly evidence that ongoing and individualized environmental stimulation/enrichment is likely a key element in facilitating further neurorecovery and maintaining achieved gains (Ashley, 2012). Importantly, the aforementioned discussion does not address how additional interventional variables can either augment or complement the effects of EE. Issues such as the timing, context and content of PAR including the psychosocial environment, quality and intensity of therapy services, medical expertise, diet, and other factors may all contribute to improved quality of life as well as functional and neurological recovery. As one example of the aforementioned, recent animal research has shown that the effects of even low dose EE can be augmented with certain medications (de la Tremblaye, et al, 2017).

Regardless of the type of post-acute program, intensity seems to be well correlated with level of functional gain if there is active rehabilitation occurring as opposed to post-acute programs that just provide supported living services. Postacute community based treatment, even when of lower intensity, can improve survivor ability to function more independently and result in less supportive care needs, the latter thereby decreasing caregiver burden.

Studies examining the effects of EE on sensory cortices have generally demonstrated alterations in neuronal responsivity and suggest that cortical plastic changes seen with EE operate independently of other previously described mechanisms of neuroplasticity (Alwis, 2014). Multiple mechanisms are involved in induction of EE-related changes in molecular function and, as a result, also in brain morphology and neuronal function. Data strongly suggests that EE may serve to facilitate neuroplasticity and modify aberrant neuronal activity in a way that promotes function as opposed to dysfunction following traumatic brain injury. It has been theorized that EE may have therapeutic benefit due to balancing cortical excitation and inhibition; thereby, improving behavior, whether cognitive or sensorimotor (Alwis, 2014). Pleiotropic interventions, including not only EE but also such interventions as exercise and task specific training (probably in combination with other treatments), can clearly enhance motor recovery after acquired brain injury (Livingston-Thomas, et al, 2016; Mala et al, 2017) and may also improve cognitive recovery.

What evidence exists to show that PAR results in long-term functional gains? Studies have found functional benefits of PAR as well as decrements in life-long cost projections resulting in overall economic savings (Seale, et al, 2002; Braunling-McMorrow, et al, 2010; Duchnick, et al, 2015; Griesbach, et al, 2015). Greisbach et al found an average of $2 million life-time cost reduction associated with PAR. Geurtsen and colleagues conducted a systematic review of the efficacy of comprehensive rehabilitation programs for adults in the chronic phase of severe acquired brain injury. While there were some methodological limitations in their analysis, substantial improvement in daily life functioning and community integration including work reentry with persistence of gains at follow-up resulted from such programming (Geurtsen, et al, 2010). Furthermore, research has shown that post-acute rehabilitation is not only associated with functional gains but that those gains cannot be explained by undirected recovery alone (Hayden et al, 2013).

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Regardless of the type of post-acute program, intensity seems to be well correlated with level of functional gain if there is active rehabilitation occurring as opposed to post-acute programs that just provide supported living services (Eicher, 2012). Post-acute community based treatment, even when of lower intensity, can improve survivor ability to function more independently and result in less supportive care needs, the latter thereby decreasing caregiver burden (Eames et al, 1996; Wood et al, 1999; Worthington et al, 2006; Middag-van Spanje et al, 2017). Gains achieved during PAR are generally maintained at long-term follow-up; although, this is not a universal finding and there are likely many factors that influence maintenance of gains (Ashley et al, 1997; Sanders et al, 2001; Geurtsen et al, 2010 and 2012). The implications, however, are that there is a need for long-term regular surveillance by specialized professionals familiar with TBI chronic care as well as long-term services that engage and stimulate patients after moderate to severe TBI to help prevent decline.

Does the intensity of PAR rehabilitation therapies matter? Multiple lines of research have shown the benefit of more intensive therapy as a key factor in activity-based therapies across skilled and non-skilled interventions (Breceda et al, 2013). In a study published in 2001, the general principal that more rehabilitation is better than less was addressed by Sheil and colleagues in a two center, prospective, controlled study with random allocation as to groups. Increasing intensity of rehabilitation therapy without change in content was associated with enhanced functional recovery and shorter hospital stays when an integrated service was delivered that provided ongoing community support. Interestingly, there was no evidence of any ceiling effect of therapeutic intensity beyond which no further response was observed (Shiel, 2001). A prospective, multicenter, non-randomized assessment of inpatient treatment intensity found therapy intensity was predictive of motor functioning at discharge but did not predict cognitive gain. Age predicted the intensity of both psychologic and total therapy services (Cifu et al, 2003). A synthesis of best evidence compiled in a Cochrane review of randomized controlled trials was compared with the literature examining long-term neurological conditions concluded: 1. strong evidence exists that more intensive programming was associated with more rapid functional gain; and 2. moderate evidence that continued outpatient therapy could assist in sustaining gains made in earlier PAR (Turner-Stokes, 2008). Other researchers have shown that cognitive and functional recovery after acquired brain injury can be optimized by more intensive rehabilitation therapy to help the brain repair itself and facilitate neuroplasticity (Wang et al, 2016).

What is the proper duration of PAR? PAR addresses one of the single most variable diseases in medicine. Brain injury varies with the nature, mechanism, and location of the injury and is further complicated by age, gender, genome, comorbid conditions at the time of injury, socioeconomic status, education, and intelligence, at least.

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While disease management for other organs proceeds along clear clinical pathways, the endpoint for PAR is far more patient-specific, variable, and dependent upon interactions of combinations of the above factors. To that end, Dobkins suggested that termination of neurological rehabilitation should depend upon the period of time during which the individual fails to make further improvement (Dobkins, 2005); however, one must differentiate between neurological improvement per se and a patient’s ability to make functional gains even without ongoing neurological change. Additionally, ongoing rehabilitative intervention may serve to prophylax against later decline and must therefore be considered in the context of such decisions to terminate therapy. Several studies have reported PAR treatment intervention periods exceeding several months (Wood et al, 1999; Worthington et al, 2006; Ashley et al, 1993; Klonoff et al, 2001; Cope et al, 1991). These studies provide support for the notion that late rehabilitation can be effective in improving functional capabilities even though longer treatment durations may be necessary to accomplish those gains. A more recent study reported comparisons between mean durations of PAR for individuals with TBI or CVA, and highlighted differences in variability among the two groups for PAR that was uninterrupted by insurance coverage and within months of injury rather than years. Both group treatment duration means were over 200 days with far more variability in the TBI group than the CVA group (Griesbach et al. 2015). This treatment duration finds support in earlier reports of larger study populations (Ashley et al, 1993; Cope et al, 1991; Turner-Stokes, 2007).

Why advocate for PAR? Implications for prophylaxis of neural and cognitive decline post-TBI. Cost containment measures by third party insurance companies and other payors limit and/or direct care without necessarily being attuned to current scientific evidence substantiating the benefits of early and ongoing treatment. The aforementioned practice results in treatment often being terminated prematurely to decrease cost exposure, or, alternatively, not being provided or paid for at all. A prime example of this is the observed substantial reduction in acute inpatient rehabilitation length of stay over the last 20 years (Kreutzer et al, 2001). Many patients with moderate to severe TBI end up being discharged to non-specialized nursing homes where they receive little or no ongoing rehabilitation. This change in care provision only further amplifies the need for advocating for postacute continuation of specialty services as the literature has clearly shown that those individuals with moderate to severe brain injury who receive more intensive rehabilitation services earlier than later show greater levels of functional improvement. Additionally, as is implied above, earlier treatment results in better functional outcomes than delayed treatment assuming treatment is even provided (Turner-Stokes, et al, 2015). Importantly, a proportion of patients (approximately 25-40% depending on the study referenced) show a tendency towards decline in function over life span after more significant TBI. The aforementioned fact has implications relative to treatment that may serve to protect against such deterioration (Kolakowsky-Hayner, et al, 2012; McMillan, 2012; Wilson, et al, 2017)). Advancing age alone does not account for the observed decline nor does impaired cognitive functioning (Griesbach et al, 2017; Wilson, et al, 2017). There is accelerated cognitive decline following more severe traumatic brain injury, particularly in areas of attention and working memory that have been apportioned to diminished cognitive reserve, which may potentially increase the risk of dementia (Wood, 2017).

Aside from the evidence from basic science as well as clinical studies supporting the benefit to such treatment, the benefit, and cost savings over time for patients and/or society at large has been well demonstrated (Ashley et al, 1990; van Heugten, et al, 2011; Greisbach et al, 2015).

Future directions and conclusions We hope that this article will stimulate interest in prospective and controlled research that further delineates factors that drive better outcomes from PAR, determine ways to modulate or negate neurological and functional decline through proactive assessments and treatments, and demonstrate the cost efficacy of different levels of PAR services. Most importantly, we must advocate for our patients and their families and know the literature that supports the services that we are claiming are medically necessary. Furthermore, we must educate payors regarding the scientific evidence that supports what we do, and what they should consider as standard and evidence based treatments. References Alwis DS, Rajan R. Environmental enrichment and the sensory brain: The role of enrichment in remediating brain injury. Frontiers in Systems Neuroscience. 8:1-20, 2014. Ashley MJ. Repairing the injured brain: Why proper rehabilitation is essential to recovering function. Cerebrum. Epub 2012 Jul 30. Ashley MJ, Krych DK, Lehr RP. Cost-benefit analysis for post-acute rehabilitation of the traumatically brain injured patient. Journal of Insurance Medicine. 22: 156-161, 1990. Ashley MJ, Persel C, Krych DK. Changes in reimbursement climate: Relationship among outcome, cost, and payor type in the post-acute rehabilitation environment. Journal of Head Trauma Rehabilitation. 8(4), 30-47, 1993. Ashley MJ, Persel CS, Clark, MC, Krych, DK. Long-term follow-up of post-acute traumatic brain injury rehabilitation: A statistical analysis to test for stability and predictability of outcome. Brain Injury. 11(9), 677-690. Brasure M, Lamberty GJ, Sayer NA, et al. Multidisciplinary post-acute rehabilitation for moderate to severe traumatic brain injury in adults. Agency for Health Care Research and Quality. 72: 1–33, 2012. Braunling-McMorrow D, Dollinger SJ, Gould M, et al. outcomes of postacute rehabilitation for persons with brain injury. Brain Inj. 24(7-8):928-938, 2010. Breceda EY, Dromerick AW. Motor rehabilitation and stroke in traumatic brain injury: Stimulating and intense. Curr Opin Neurol. 26(6): 595–601, 2013. Cifu DX, Kreutzer JS, Kolakowsky-Hayner SA, et al. The relationship between therapy intensity and rehabilitative outcomes after traumatic brain injury: A multicenter analysis. Arch Phys Med Rehabil. 84(10):1441-1448, 2003.

Klonoff PS, Lamb DG, Henderson SW. Outcomes from milieu-based neurorehabilitation at up to 11 years post-discharge. Brain Injury. 15(5):413-428, 2001. Kolakowski-Hayner SA, Hammond FM, Wright J, et al. Aging and traumatic brain injury: Age, decline in function and level of assistance over the first 10 years post-injury. Brain Injury. 26 (11): 1328–1337, 2012 Kreutzer JS, Kolakowsky-Hayner SA, Ripley D, et al. Charges and lengths of stay for acute and inpatient rehabilitation treatment of traumatic brain injury. Brain Injury. 15(9):763-774, 2001. Livingston–Thomas J, Nelson P, Karthikeyan S, et al. Exercise as enablers of task specific neuroplasticity and stroke recovery. Neurotherapeutics. 13:395–402, 2016. Mala H, Rasmussen CP. The effect of combined therapies on recovery after acquired brain injury: Systematic review of preclinical studies combining enriched environment, exercise, or task specific training with other therapies. Restorative Neurology and Neuroscience. 35: 25–64, 2017. Malec JF, Basford JS. Post-acute brain injury rehabilitation. Arch Phys Med Rehab. 77: 198-207, 1996. McMillan TM, Teasdale GM, Stewart E. Disability in young people and adults after head injury: 12-14 year follow-up of a prospective cohort. J Neurol Neurosurg Psychiatry. 2012;83:1086–91. doi: 10.1136/jnnp-2012302746. Middag-van Spange M, Smeets S, van Haastregt J, van Heugten C. Outcomes of a community based treatment programme for people with acquired brain injury in the chronic phase: A pilot study Neuropsychol Rehabil. 2017, March 28, Epub ahead of print. Sander AM, Roebuck TM, Struchen MA, et al. Long-term maintenance of gains obtained in post-acute rehabilitation of persons with traumatic brain injury. J Head Trauma Rehabil. 16(4): 356–373, 2001. Seale GS, Caroselli JS, High WM, et al. Use of community integration questionnaire to characterize changes in functioning for individuals with traumatic brain injury participated in a postacute rehabilitation programme. Brain Inj. 16(11):955-967, 2002. Shiel, A, Burn JPS, Henry D, et al. The effects of increased rehabilitation therapy after brain injury: Results of a prospective controlled trial. Clinical Rehabilitation. 15:501–514, 2001. Sours C, George EO, Zhuo J, et al. Hyper-connectivity of the thalamus during early stages following mild traumatic brain injury. Brain Imaging Behavior. 9(3):550-563, 2015. Turner-Stokes, L. Cost-efficiency of longer-stay rehabilitation programmes: Can they provide value for money? Brain Injury. 21(10): 1015-1021, 2007. Turner-Stokes, L. Evidence for the effectiveness of multidisciplinary rehabilitation following acquired brain injury: A synthesis of two approaches. Journal of Rehabilitation Medicine. 40: 691-701, 2008. Turner-Stokes L, Pick A, Nair A, et al. Multidisciplinary rehabilitation for acquired brain injury in adults of working age. Cochrane Database Syst Rev. Dec 22;(12):CD004170, 2015. Van Heugten CM, Geurtsen GJ, Derksen RE. Intervention and societal costs of residential community reintegration for patients with acquired brain injury: A cost-analysis of the brain integration programme. J Rehabil Med. 43:647-652, 2011. Wang L, Conner JM, Nagahara AH, Tuszynski MH. Rehabilitation drives enhancement of neuronal structure and functionally relevant neuronal subsets. PNAS. 113(10):2750-2755, 2016. Wilson L, Stewart W, Dams-O’Connor K, et al. The chronic and evolving neurological consequences of traumatic brain injury. The Lancet Neurology. 16(10):813-825, 2017. Wogensen E, Mala H, Mogensen J. The effects of exercise on cognitive recovery after acquired brain injury in animal models: A systematic review. Neural Plas. E-pub Oct. 5, 2015. Wood RL, McCrea JD, Wood LM et al. Clinical and cost-effectiveness of post-acute neurobehavioral rehabilitation. Brain Injury. 13(2):69-88, 1999. Wood RL. Accelerated cognitive aging following severe traumatic brain injury: A review. Brain Inj. 31(10):1270-1278, 2017. Worthington AD, Matthews S, Melia Y, et al. Cost-benefits associated with social outcome from neurobehavioral rehabilitation. Brain Injury. 20(9):947-957, 2006.

Cope N, Cole, J, Hall K, et al. Brain Injury: Analysis of outcome in a post-acute rehabilitation system: Part1: General Analysis. Brain Injury. 5:111-125, 1991. Cullen N, Meyer MJ, Aubut JA, et al. Efficacy and models of care following acquired brain injury. Evidence based review of moderate to severe acquired brain injury. ERABI. Accessed 12/1/17. http://www.abiebr. com/ De la Tremblaye PB, Wellcome JL, de Witt BW, et al. rehabilitative success after brain trauma by augmenting a subtherapeutic dose of environmental enrichment with galantamine. Neurorehabilitation and Neural Repair. 31(10–11):977–985, 2017. Duchnick JJ, Ropacki S, Yutsiss M, et al. Polytrauma transitional rehabilitation programs: comprehensive rehabilitation for community integration after brain injury. Psychological Services. 12 (3): 313-321, 2015. Eames P, Cotterill, G, Kneale, TA Storrar AL, Yeomans P. Outcomes of intensive rehabilitation after severe brain injury: AS long-term follow-up study. Brain Injury. 10(9): 631-650, 1996. Eicher V, Murphy MP, Murphy TF, Malec JF. Progress assessed with the Mayo–Portland Adaptability Inventory in 604 participants in 4 types of post-inpatient rehabilitation brain injury programs. Arch Phys Med Rehabil. 93(1):100-107, 2012. Frasca D, Tomaszczyk J, McFadyen BJ, Green RE. Traumatic brain injury and post-acute decline: What role does EE play? A scoping review. Frontiers in Human Neuroscience. 7:31, 2013. Geurtsen GJ, van Heughten CM, Martina JD, Geurts ACH. Comprehensive rehabilitation programmes in the chronic phase after severe brain injury: A systematic review. J of Rehab Med. 42: 97-110, 2010. Geurtsen GJ, van Heughten CM, Martina JD, et al. 3-year follow-up results of a residential community reintegration program for patients with chronic acquired brain injury. Arch Phys Med Rehabil. 93:908911,2012 Glenn MB, Rotman M, Goldstein R, Selleck EA. Characteristics of residential community integration programs for adults with brain injury. J Head Trauma Rehabil. 20(5): 393–401, 2005. Griesbach, G.S., Kreber, L.A., Harrington, D and Ashley, M. Post-acute traumatic brain injury rehabilitation: Effects on outcome measures and life care costs. J of Neurotrauma. 32:704-711, 2015. Griesbach GJ, Masel BE, Helvie RE, Ashley MJ. The impact of traumatic brain injury on later life: Effects of normal aging and neurodegenerative diseases. J of Neurotrauma. 2017 Oct 27. doi: 10.1089/neu.2017.5103. [Epub ahead of print]. Hayden ME, Plenger P, Bison K, et al. Treatment effect versus pretreatment recovery in persons with traumatic brain injury: A study regarding the effectiveness of post-acute rehabilitation. PM&R. 5:319–327, 2013.

Author Bios Nathan Zasler, MD, is founder, CEO & CMO of Concussion Care Centre of Virginia, Ltd. and Tree of Life Services, Inc.. He is board certified in PM&R, fellowship trained in brain injury and subspecialty certified in Brain Injury Medicine. Dr. Zasler has several academic appointments and lectures nationlly and internationally on topics related to brain injury. Dr. Zasler has published extensively on TBI related neuromedical issues. He is cochief editor of “Brain Injury” and “NeuroRehabilitation” and serves on numerous journal editorial boards. Dr. Zasler is active in local, national and international organizations dealing with acquired brain injury and neurodisability. Mark Ashley, ScD, CCC-SLP, CCM, CBIST, is President/CEO of Centre for Neuro Skills® (CNS), which has operated postacute brain injury rehabilitation programs since 1980. Dr. Ashley serves on the Board of Directors of the Brain Injury Association of America, and is an Emeritus Chair. He serves on the Board of Directors of the California Brain Injury Association. Dr. Ashley is an Adjunct Professor at the Rehabilitation Institute of the College of Education at Southern Illinois University. Dr. Ashley founded the Centre for Neuro Skills Clinical Research and Education Foundation, a nonprofit research organization.

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What Should Comprehensive Neurorehabilitation in a Transitional Residential Rehabilitation Program Look Like? Gary S. Seale, PhD • Brent E. Masel, MD

Introduction Traumatic brain Injury (TBI) is a serious public health problem in the United States, and a leading cause of death and disability. The physical, cognitive, emotional and behavioral consequences of TBI are well documented, and often persist for months to years following injury. Some impairments stemming from TBI may be lifelong. Given that TBI frequently affects young adults and occurs at a time when important milestones are being reached, such as graduating from high school, entering college, launching a career, or getting married, aggressive and well-designed neurorehabilitation is necessary to ensure successful reintegration into the community (Khan et al., 2003). This article will present the essential therapeutic and medical components of TRR programs that promote restoration of function, participation in meaningful activities and significant life roles, and improve life satisfaction and quality of life.

Continuum of Care Since the late 1970’s/early 1980’s, a specialized continuum of care has evolved to address the multiple and complex changes caused by TBI (Bontke and Boake, 1991). Medical management immediately following injury (i.e., emergency medicine; intensive/ critical care) and acute rehabilitation are hospital-based and focus on management of medical emergencies and complications, medical stability, and re-establishment of basic functional skills (transfers and mobility, communication, basic activities of daily living, etc.). A large percentage of persons with moderate to severe brain injury are not ready to return home following acute rehabilitation due to on-going medical issues (seizure disorders, endocrine dysfunction, etc.), or physical, cognitive, and behavioral profiles that place them at high risk for further medical complications and re-injury. These patients require further intensive treatment. Transitional residential rehabilitation (TRR) programs provide on-going medical management, as well as the appropriate level of structure, supervision, and intensity of skilled therapies necessary to promote independence and a safe transition to the community.

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Components of Effective Transitional Residential Rehabilitation Programs There is considerable evidence supporting the effectiveness of TRR programs in improving activities of daily living (Geurtsen et al., 2008), cognition (attention, memory), communication, and executive functioning (Cicerone et al., 2000 & 2005), behavioral control (Wood et al., 1999), and vocational skills (Shames et al., 2009). So effective are TRR programs that they are considered best practice, or standard of care following TBI (Tsaousides and Gordon, 2009).

The Role of Comprehensive, Interdisciplinary Treatment & Clinical Practice Guidelines TRR programs are comprehensive and interdisciplinary or transdisciplinary in nature, delivering skilled therapies in multiple health profession disciplines in a holistic fashion. A comprehensive approach is necessary to address the complex needs of persons with TBI previously mentioned. An inter- or transdisciplinary approach is necessary to ensure the blending of common core clinical skills, sharing responsibility for therapeutic interventions and outcomes, pooling of resources for efficiency, and promoting a patient-centered approach to treatment (Pethybridge, 2004). Clinical practice guidelines that are informed by systematic reviews of the literature are used to guide clinicians and optimize patient care.

The Role of Treatment Intensity, Duration, and Setting TRR programs deliver therapeutic interventions at an appropriate intensity and duration to achieve preferred patient outcomes. Greater treatment intensity is associated with better functional outcomes and reduced lengths of stay (Kahn et al., 2003; Zhu et al., 2009). Comprehensive TRR programs may provide up to 5-8 hours of skilled therapy daily.

Therapeutic interventions include remediation techniques, compensatory strategies, assistive technology and environmental modifications to improve function. Skills and strategies taught in the clinic are transitioned to community-based venues (banks, grocery stores, restaurants, etc.) to ensure generalization to the discharge community. This exposure to real-world experiences in environmentally relevant contexts promotes adaptive neural plasticity. However, in practice, there is great variability in TRR treatment programs with regard to clinical (i.e., licensed professionals) and non-professional staffing, patient injury characteristics and demographics, and treatment components (Glenn et al., 2004). Ultimately, therapy intensity and lengths of stay are driven by a host of factors including patient injury severity and accompanying impairments (Cioe, 2016), access to essential clinical and medical components of TRR programs, and constraints imposed by payors (Ashley et al., 1993). In many TRR programs, skilled therapies are complemented by protocol-driven training delivered by non-professional staff that act as “therapy extenders”. These staff, well trained and often credentialed as Nursing Assistants or Brain Injury Specialists, provide patients opportunities for rehearsal and repetition of skills and strategies in environmentally valid contexts in the community. This community-based training has a positive influence on functional outcomes. As the ultimate goal of TRR programs is reintegration into the community and resumption of meaningful daily activities (meal preparation, budgeting and banking, community mobility and transportation, etc.) and participation in significant life roles (spouse, parent, home maker, breadwinner, etc.), an extended treatment duration is required. The literature suggests a duration of 28 to 52 weeks (Geurtsen et al., 2010); however, the maximum rehabilitative potential for persons with moderate to severe TBI has not been definitively delineated.

The Role of the Rehabilitation Physician Persons entering TRR programs are medically stable but are not “cured”, and require on-going medical management. Brain injury is no longer considered a static event. It is now recognized that in many individuals, a TBI is the beginning of a chronic disease-like process (Masel and DeWitt, 2010). Post traumatic seizures are seen in approximately 16% of individuals with severe TBI (Annegars et al., 1998) with a latency of onset of as long as 12 years (Aarabi et al., 2000). Post-traumatic neuroendocrine dysfunction occurs in approximately 30-40% of individuals with TBI (Schneider et al., 2007), and can significantly impact the rehabilitation process. Sleep disorders are prevalent following TBI (Masel et al., 2001) and have a negative impact on cognition. The unmasking as well as the de novo development of psychiatric disease is, unfortunately, common following TBI. As individuals are referred to TRR programs earlier, post brain injury confusion, agitation and aggression are commonly sequelae, as are the psychiatric sequelae more often associated with the later effects of the brain injury such as depression, mood disorders, anxiety and obsessive-compulsive behavior. (Zasler et al., 2012). The development of spasticity is common early following a TBI (Elovic et al., 2004) and must be treated quickly and effectively for early ambulation and independence. Clearly, medical practitioner(s) associated with the TRR program must be knowledgeable in Physiatry, Neurology, Internal Medicine and Psychiatry, and stay abreast of a rapidly expanding literature. Clinical practice guidelines have been proposed for hormone replacement, and emerging evidence points to benefits of treating sleep disorder and disturbances in protein synthesis that frequently accompany TBI. Non-invasive brain stimulation (i.e., transcranial magnetic stimulation) is a promising intervention for motor recovery.

The Role of Case Manager and Coordinated Treatment Treatment delivered in a coordinated fashion, facilitated by a case manager, is necessary to ensure collaboration and cooperation among team members, removal of disciplinary boundaries, and integration of external providers (specialty providers, medical follow-up, adaptive equipment/DME) into the treatment plan. Case managers focus therapy team members on patient goals and agreed-upon outcomes, provide family education and training, and advocate for patients to ensure continued access to treatment. Case managers improve efficiencies by reducing redundancies in the delivery of therapies. Integrated, interdisciplinary treatment facilitated by a case manager positively influences discharge planning and transition to home.

The Role of the Family and Family Education and Training TRR programs recognize the patient and family as important members of the treatment team. Collaboration between the family and clinicians is promoted as the treatment plan is developed, implemented, and refined. Families often express greater satisfaction with rehabilitation when they are listened to, recognized for their experience with the patient, and when they are supported at times of distress. Commonly, families desire information about the brain injury (i.e., location and severity), disabilities that may stem from injury (i.e., memory problems, mobility, ADL’s, etc.), and information regarding recovery (Lefebvre et al., 2005). Therapists and case managers must recognize the magnitude of challenges facing the family and balance the imparting of accurate information with emotional support. Given that most individuals with TBI are discharged home to the care of family members, thorough training of care givers is paramount. Family care givers interface with the treatment team and receive training not only in safe transfers, ADL techniques, use and care of adaptive equipment, and dietary consistencies and swallowing safety, but also medication regimens, sleep hygiene, and methods to manage seizures and behavioral dysregulation. The complex and long-term demands placed on the family after TBI can be overwhelming. TRR programs provide counseling to families to address grief associated with loss, and uncertainty about the future. Effective communication strategies, realistic boundary setting, healthy coping techniques, and reappraisal/reassignment of family roles are the focus of family counseling.

The Role of Discharge Planning, Follow-up, and Outcomes Reporting Thoughtful discharge planning, periodic follow-up, and outcomes measurement and reporting are components of TRR programs. Discharge planning involves not only identifying current needs and a focus on the immediate discharge environment, but also the long-term needs and potential problems the patient and family may encounter. Immediate needs at discharge may include ensuring home modifications are in place, adaptive equipment and DME have been delivered, and follow-up appointments with medical specialties are scheduled. Encouraging family to allow the patient to engage in ADL’s independently, maintain a daily rhythm and activity schedule, attend a support group and avoid high risk activities to reduce the probability of re-injury are also the focus of near-term discharge planning.

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Longer range planning identifies activities and resources to support quality of life, such as engagement in productive activities (work, school, volunteer activities), opportunities for social engagement (support groups, church), and intermittent rehabilitation to avoid isolation, development of mood disorders, and maladaptive coping strategies (i.e., substance misuse). Promoting an enriched environment (exercise, cognitive and social stimulation) may slow age-related cognitive decline. Participation in periodic follow-up initiated by the facility or the family can assist with early problem detection and allow the family to connect with local resources to avoid crises. Additionally, periodic follow-up incorporating problemsolving strategies, emotional support, and positive psychology practices to promote resilience, may reduce isolation and onset of negative emotional states (i.e., anxiety, depression).

Advances in medicine, such as hormone replacement, dietary supplementation, and non-invasive brain stimulation, and the incorporation of positive psychology practices during follow-up, and exposure to enhanced environments for the long term may further improve effectiveness of TRR programs and maintenance of outcomes.

TRR programs collect and report outcomes data to objectively measure response to treatment and maintenance of gains made during rehabilitation.

Bontke, CF & Boake C. Traumatic brain injury rehabilitation. Neurosurgery Clinics of North America. 2:473482, 1991.

References Annegers J, Hauser A, Coan S, et al., A population-based study of seizures after traumatic brain injuries. New England Journal of Medicine. 338:20-24, 1998. Aarabi B, Taghipour M, Haghnegahdar A, et al., Prognostic factors in the occurrence of posttraumatic epilepsy after penetrating head injury suffered during military service . Neurosurgical Focus. 8:1-6, 2000. Ashley MJ, Persel CS & Krych DK. Changes in reimbursement climate: Relationship among outcome, cost and payor type in the postacute rehabilitation environment. Journal of Head Trauma Rehabilitation. 8:30-47, 1993.

Cicerone KD, Dahlberg C, Kalmar K, et al., Evidenced-based cognitive rehabilitation: Recommendations for clinical practice. Archives of Physical Medicine & Rehabilitation. 81:1596-1615, 2000. Cicerone KD, Dahlberg C, Malec JF, et al., Evidenced-based cognitive rehabilitation: Updated review of the literature from 1998-2002. Archives of Physical Medicine and Rehabilitation. 85:1681-1692, 2005. Cioe N, Seale GS, Marquez de la Plata C, et al., Brain injury rehabilitation outcomes. Vienna, VA: Brain Injury Association of America, 2016.

Information obtained from outcomes data analysis helps identify family and patient characteristics associated with outcome, assists families in making decisions about the quality and appropriateness of a particular TRR program, and can add to the growing body of literature supporting the effectiveness of TRR programs.

Elovic EP, Simone LK, Zafonte R. (2004) Outcome assessment for spasticity management in the patient with traumatic brain injury: The state of the art. Journal of Head Trauma Rehabilitation. 19:155-177, 2004. Geurtsen GJ, Martina JD, van Heugten CM, et al., A prospective study to evaluate a new residential community integration programme for severe chronic brain injury: The brain integration programme. Brain Injury. 22:545-554, 2008. Geurtsen GJ, Van Heugten, CM, Martina JD, et al., Comprehensive rehabilitation programmes in the chronic phase after severe brain injury: A systematic review. Journal of Rehabilitation Medicine. 42:97-110, 2010. Glenn MB, Goldstein R, Selleck EA, et al., Characteristics of facility-based community integration programs for people with brain injury. Journal of Head Trauma Rehabilitation. 19:482-493, 2004. Khan F, Baguley IJ, Cameron, ID. Rehabilitation after traumatic brain injury. Medical Journal of Australia.178:290-295, 2003. Lefebvre H, Pelchat D, Swaine B, et al., The experiences of individuals with a traumatic brain injury, families, physicians and health professionals regarding care provided throughout the continuum. Brain Injury.19:585-597, 2005. Masel BE, & DeWitt DS (2010). Traumatic brain injury: A disease process, not an event. Journal of Neurotrauma. 27:1529–1540, 2010. Masel BE, Scheibel RS, Kimbark T, et al., Excessive daytime sleepiness in adults with brain injuries. Archives of Physical Medicine and Rehabilitation. 82:1526–1532, 2001.

Conclusion Comprehensive TRR programs are effective and considered best practice or standard of care following TBI. A number of key components coalesce to produce positive outcomes that promote engagement in meaningful activities, participation in significant life roles, and improve quality of life. These components include an involved and knowledgeable rehabilitation physician, use of evidenced-based clinical practice guidelines, intensive integrated interdisciplinary therapy coordinated by a case manager, family involvement and periodic follow-up.

Pethybridge J. How team working influences discharge planning from hospital: A study of four multidisciplinary teams in an acute hospital in England. Journal of Interprofessional Care. 18:29-41, 2004. Schneider H, Kreitschmann-Andermahr I, Ezio GE, et al., Hypothalamopituitary dysfunction following brain subarachnoid and aneurysmal hemorrhage: A systematic review. JAMA. 298:1429-1438, 2007. Shames J, Treger I, Ring H, et al., Return to work following traumatic brain injury: Trends and challenges. Disability and Rehabilitation. 29:1387-1395, 2009. Tsaousides, T & Gordon WA. Cognitive rehabilitation following traumatic brain injury: Assessment to treatment. Mount Sinai Journal of Medicine. 76:173-181, 2009. Wood RLI, McCrea JD, Wood LM, et al., Clinical and cost effectiveness of post-acute neurobehavioral rehabilitation. Brain Injury. 13:68-88, 1999. Zasler ND, Katz DI, & Zafonte, RD: Brain Injury Medicine: Principles and Practice. New York: Demos Medical Publishing, LLC, 2013. Zhu XL, et al., Does intensity of rehabilitation improve functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial. Brain Injury. 21:681-690, 2007.

Author Bios Gary S. Seale, PhD, is Regional Director of Clinical Services for the Centre for Neuro Skills. He received his doctoral degree in Rehabilitation Science from the University of Texas Medical Branch (UTMB) in Galveston, Texas. He is licensed in Texas as a Psychological Associate and Chemical Dependency Counselor, and holds a clinical appointment at UTMB in the School of Health Professions – Department of Rehabilitation Science. He has worked exclusively in post-acute brain injury rehabilitation for over 27 years and has conducted research and published peer-reviewed articles on topics including rehabilitation outcomes, the relationship between positive emotion and recovery of functional status following stroke, and emergency preparedness for disabled populations. Brent E. Masel, MD, is the Executive Vice-President for Medical Affairs with the Centre for Neuro Skills and is a Clinical Professor of Neurology at the University of Texas Medical Branch in Galveston. He has been a Board Certified Neurologist for 40 years, and has conducted research in the field of brain injury with over 40 publications in the areas of brain injury rehabilitation including virtual reality, hyperbaric oxygen treatment, sleep abnormalities, metabolic abnormalities, hormonal dysfunction, and the long term medical issues from chronic brain injury.

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Post-acute Transitional Residential Rehabilitation and Changes in Decision-Making Capacity Margaret Kroese, MSSW • Martin J. Waalkes, PhD, ABPP, CBIST

Post-acute transitional residential rehabilitation (TRR) is an intensive, post-hospitalization rehabilitation service model that focuses on functional recovery and disability mitigation. TRR programs provide highly integrated therapy interventions in order to maximize recovery and actively build the supports needed in the home community upon discharge. The goal of TRR is to restore a person to their most independent level of functioning. By necessity, TRR is both intense in duration and activity. Postacute programs provide formal treatment for up to six hours per day, at least five days per week. Additionally, Rehabilitation Aides reinforce the treatment goals during morning and evening routines, as well as throughout all other activities of daily living. Treatment length varies based on the person’s needs, but typically is between 60 – 90 days. While not hospital based, TRR is experienced as an inpatient program, meaning the participant typically lives within the treatment program for the duration of care. The treatment environment and distinct population characteristics found in the post-acute brain injury rehabilitation setting present unique ethical challenges relevant to patient decision-making capacity. Sustaining a brain injury results in readily apparent changes like physical and language changes, as well as less obvious changes like slowed thought, limited judgment or insight, and impaired memory. Cognitive consequences of the injury may affect a person’s ability to make informed decisions regarding medical treatment and lifestyle choices. In general, patients seeking medical care need the ability to understand information relevant to the medical decisions being asked of them, and to appreciate the consequences of any decision, or lack of decision, to be truly informed. Patients without this ability need a formal or informal decision maker to assist them. In postacute brain injury rehabilitation, persons being served may move from needing assistance to having independent decision-making capacity as they progress. Professionals in these programs must recognize, support, and respond to changes in capacity over the course of a treatment program. Early in recovery and during the adjustment to the profound changes of a severe brain injury, decision-making capacity is often absent.

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Concerns of initiating treatment and weighing the likelihood of benefiting from intervention are protected by proxy decision makers with little contribution by the patient in a minimally conscious or vegetative state. This condition alone, with the uncertainties of prognosis, provokes many questions of informed consent and rights to treatment (Fins, 2015). While less grave than life and death, serious questions of quality of life and the expression of individual preferences remain. As patients show signs of awareness and can communicate their values and desires, decision makers have an obligation to reflect these wishes in the decision-making process. Many people arrive at the post-acute level of care without the ability to determine their own course of treatment. Medical decisionmaking capacity that was significantly impaired in patients with moderate to severe TBI at the end of their acute care hospitalization can show substantial improvement and partial recovery of the abilities over a 6-month period (Marson, Dreer, Krzywanski, Huthwaite, DeVivo, & Novack, 2005). The changing level of a patient’s capacity observed as the injury and related symptoms resolve is a unique factor found in brain injury rehabilitation. A person’s decisional capacity is a clinical determination by a qualified medical professional, typically a psychologist or physician with background and training in this area of assessment. While considering the person’s capacity, the psychologist or physician must consider how the current medical treatment, cognitive status, and emotional, social, and contextual situation contribute to the current presentation (Hanson, Kerkhoff, & Bush, 2005). The Aide to Capacity Evaluation (ACE) is a frequently used structured interview assessment that can guide a thoughtful assessment of the domains of a capacity determination (University of Toronto - Joint Centre for Bioethics, 2003). A capacity assessment should determine the presence of the following: (1) the ability to understand the information relevant to the choice; (2) the ability to reason or rationally evaluate the choice; (3) the ability to appreciate the significance of the choice; and (4) the ability to communicate and maintain a choice (Wassenaar, 2013). The ability to understand the relevant information is a basic element in demonstrating capacity. Cognitive deficits in comprehension, memory, or attention, which are common in brain injury, may limit the ability to truly understand the situation and choices available.

Anosognosia (a lack of awareness of the injury or the resulting deficits) can influence the ability to appreciate the nature of the injury or the challenges it presents. The ability to reason refers to maintaining a decision-making process whereby information is weighed and compared in coming to a decision. Common symptoms of brain injury include impulsivity, irritability, memory problems, impaired reasoning, and problem solving. These and other cognitive-behavioral impairments influence decision-making quality. The ability to appreciate the significance of the choice relates to the ability to apply the consequences of the choice to one’s own life considering and integrating values and preferences. This is demonstrated by showing an understanding of the possible outcomes and implications of choices on the individual’s life relative to endorsed values. This type of reflective capacity requires perspective-taking and is often limited by brain injury. Communicating a decision requires being able to express your ideas and desires to another person. Survivors of brain injury may have difficulty expressing choice verbally due to muscle weakness or other physical consequences of brain injury. However, they may still express intact capacity of their choice by other means of communication, such as technological solutions. People who experience expressive aphasia (loss of the ability to formulate language) may be sufficiently limited in their ability to communicate choices as to require decision-making support simply to express their wishes. In some cases, variable awareness and fluctuating investment creates an instability of decision expression, requiring support simply to establish necessary consistency needed for treatment. Adding complexity to the post-acute setting, a person being served can maintain capacity in some areas of decision-making while not being considered to have capacity to make other decisions, and this can fluctuate from day-to-day (Wassenaar, 2013). Factors such as medications, external stresses, and mood or thought disorders can influence understanding, appreciation, and a rational decisionmaking process. Decision-making capacity is expected to change during early treatment for brain injury. To address this, most post-acute programs incorporate structured assessments, neuropsychological testing, behavioral observations, and patient interviews in an ongoing treatment model. Multiple assessments over time indicate the change in capacity, and increases or reductions in need for assistance with decision-making. Treating patients with changing levels of capacity poses several ethical and programmatic challenges for TRR programs. In the acute phase of brain injury rehabilitation, it is common for a family member to serve as a proxy and make medical decisions for a loved one. Typically, this is done on an informal basis, without a legal determination of guardianship, as the person is easily presumed impaired, yet generally expected to regain capacity as they progress. By the time the individual is entering TRR, substantial medical improvement has been made allowing transition out of the acute hospital setting. However, individuals admitted to TRR may not have made enough gains in the cognitive and reasoning abilities to reassert independent decision making for medical and lifestyle decisions, making the decisional capacity question more nuanced. Often, treatment is provided with a degree of suspension of informed consent in a parental or educational effort under the presumption that a person who may be superficially refusing services may better appreciate their circumstances if they can

be first supported sufficiently to recover some of their decisional capacity through rehabilitation (Caplan, Callahan, & Haas, 1987). Ironically, increasing levels of decision-making in the recovering person can create difficulty for families. While welcoming progress in the core skills supporting decision making, families may be hesitant to relinquish their role in making decisions. This dynamic can lead to conflicts between the rights of the person being served and the desires of family who may have invested immense amounts of time facilitating care during the early recovery stage. Not only does this create potential for family conflict, it also puts the rest of the treatment team in a difficult situation. While the team must be accountable to the person being served, ongoing family support is a key factor in successful long-term outcomes in brain injury rehabilitation, and alienation of the family support is unlikely in the best interest of the injured person (Vangel, Rapport, Hanks, & Black, 2005). Ideally, these conflicts can be avoided by offering proactive family education as well as family support groups throughout the healing process. Ultimately, the treatment team is responsible to the patient’s best interests and legal rights, regardless of the family’s concerns and desires. It is common to find a patient arriving from acute rehab exhibiting confusion, agitation, inconsistent orientation, and memory impairment. By discharge, many of these features will have resolved or be substantially reduced. With this progress, gains are observed in resulting decisional capacity. Along the way, the recovering person should reassume a decision-making self-leadership role, as they are able. A typical treatment team in TRR includes many treating professionals including a physiatrist, psychologist, physical therapist, occupational therapist, speech language pathologist, social worker, rehabilitation aides, and other disciplines as required. Each team member must adjust their treatment in order to actively transition the decision-making authority to the person being served as he or she demonstrates readiness. Excellent team communication is key to making this transition one that is coordinated and successful. Not everyone will progress enough during rehabilitation to be independent in decision-making and may, instead, require formal temporary or permanent guardianship. Typically, this path will not be pursued early in rehabilitation in the hopes that gains will be made, although determination at the early stage is more straightforward. At some point, the treatment team will need a formal decision maker with full legal authority who can help establish the future plans of the individual. For those who show impulsivity or unawareness of their deficits, the issue of formal guardianship is often addressed earlier in rehabilitation in order to assist in participation and designating long-term support options. Treatment refusal can be a very good reason to seek formal guardianship for a person who does not demonstrate the capacity to make this choice. This, too, is a complex issue, as treatment refusal is a patient’s right and other factors can influence a patient in refusing treatment. Ongoing pain, medication changes and side effects, anxiety, depression, familial stress, and financial stress can all contribute to refusal of treatment, yet none of these on their own necessarily merit a loss of decision-making autonomy. Typically, a physician or psychologist will sort through all of the factors influencing treatment refusal and determine if any one, or any combination of reasons, rises to the level of concern that merits seeking formal assistance (Hanson, et al., 2005). Depending on the outcome of such evaluation, the program may determine that the team seeks the assignment of a guardian through a formal legal process with the probate court.

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A major goal of TRR is restoring the decision-making capacity The U.S. Consumer Products Safety Commission those being served in the program. In found the most successful more than 750 deaths and 25,000 hospitalizations in situations, individuals being served go from being passive its 10-year study of the dangers of portable electric generators. in their rehabilitation, to being the leader of the team, package-on-the-proposed-rule-safety-standard-forsetting their goals, and indicating their desires for their treatment portable-generators and lifestyle 8. For the choices. current guidelines: http://wedocs.unep. 7.of

References Caplan, A. L., Callahan, D., & Haas, J. Ethical and policy issues in rehabilitation medicine: A Hastings Center report. Briarcliff Manor, NY: Hastings Center, 1987. Fins, J. J. Rights come to mind: Brain injury, ethics, and the struggle for consciousness. New York: University of Cambridge, 2015. Hanson, S. L., Kerkhoff, T. R., & Bush, S. S. (2005). Health care ethics for psychologists: A casebook. Washington, DC: American Psychological Association, 2005.


Marson D. E., Dreer L. E., Krzywanski S., Huthwaite J.S., DeVivo M.J., & Novack T.A. Impairment and partial

to 30 minutes.

Mary Free Bed Hospital. Grand Rapids, MI, 2013, May 13. & Stark

recovery of medical decision-making in traumatic brain injury: You Can Trustcapacity in Brain Injury LawA 6-month longitudinal study. pollutants_guidelines.pdf?sequence=2 Decision-making capacity, while simple in concept, is a complex issue Experience Archives of Physical Medicine & Rehabilitation, 86, 889-895, 2005. 9. In an April 2017 carbon monoxide poisoning at a hotel that inhas serious implications for the success of the TRR experience. University of Toronto - Joint Centre for Bioethics. Aide to Capacity Evaluation (ACE). Retrieved from http:// Niles, Michigan, several first responders had to be, 2003. Professionals practicing in this area ofmasks medicine hospitalized because they were not wearing while experience the With 30medical years experience Vangel, S. J., Rapport, L. J., Hanks, R. A., & Black, K. L.over Long-term careof utilization and costs among they treated severely poisoned children. In a recent unique challenge of adjusting treatment and relinquishing a parental traumatic brain injury survivors. American Journal of Physical Medicine and Rehabilitation, 84, 153-160, Detroit poisoning, the first responders did not have in the area of head and brain 2005. stylecarbon of treatment direction as the patient gains the ability to take on monoxide detectors and also might have been injuries, nationally recognized Stark Wassenaar, M. Ethical perspectives on assessing decision making capacity. Grand Rounds presentation at poisoned. CO wascapacity. not determined to be the cause for 20 decision-making

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.“

Author Bios

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.

Margaret Kroese, MSSW, is the Executive Vice President of Hope Network Neuro Rehabilitation, a large post-acute and transitional residential

Bruce H. Stern, Esq. rehabilitation provider located in west and central Michigan. She has served in this leadership role at Hope Network since 2002 and in brain injury ABOUT THE AUTHOR

rehabilitation, Ms. Kroese currently sits on the Executive Board of the Coalition Protecting Auto No-Fault and recently finished her term as Gordon Johnson is since a leading advocate the Past-President of theHe Michigan Braincum Injury Provider’s Council. She has spoken at various workshops and conferences on the topic of brain injury and author on brain injury. is a 1979 rehabilitation, Michigan Auto No-Fault and the Affordable Care Act. laude graduate of the University of Wisconsin law school and a journalism grad from NorthMartin J. Waalkes, PhD, ABPP, CBIST, psychologist who has been treating individuals with brain and spinal cord injury since 1990. western University. He has authored someisofa licensed the He is a board-certified Rehabilitation Psychologist, as well as a Certified Brain Injury Specialist-Trainer. Dr. Waalkes is Director of Neuro Rehabilitation most read web pages in brain injury. He is the for Hope Network Neuro Rehabilitation where he is responsible for the development of programming and clinical services for transitional residential 1-800-53-LEGAL Past Chair of the Traumatic Brain Injury Litirehabilitation programs. He is a past vice-chair of the Michigan Board of Psychology, and has a doctoral degree in clinical psychology from Michigan gation Group, American Association of Justice. State University. He is the Hope Network psychology department supervisor, providing clinical supervision and direct service Follow Us: in behavioral evaluation, He was appointed by Wisconsin’s Governor to individual therapy, cognitive and neuropsychological assessment, consultation, and support to patients and their families. the state’s sub-agency, the TBI Task Force from 993 Lenox Drive, Lawrenceville, NJ 08648 2002 – 2005. He is also the author of two novels on brain injury, Crashing Minds and Concussion is Forever.


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its 10-year study of the dangers of portable electric 26 - 28: Third Conference generators. on Paediatric Acquired Brain Injury, package-on-the-proposed-rule-safety-standard-forportable-generators September 26 -28, Belfast, For the current guidelines: http://wedocs.unep. Northern Ireland. org/bitstream/handle/20.500.11822/8676/Select_ For more information, pollutants_guidelines.pdf?sequence=2 visit In 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

30 - 3:treated ACRMseverely 95th poisoned Annual Conference, they children. In a recent Detroit poisoning, the first responders not have September 30 - October 3, Dallas,didTexas. carbon monoxide detectors and also might have been For more information, visit poisoned. CO was not determined to be the cause for 20 to 30 minutes. 10.

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


Environmental Toxicology, sponsored by the SysteMed

March Corporation and held m Fairborn, Ohio on 9, 10th and 11 September 1970.“

13 - 16: IBIA 13th World Congress on Brain Injury, ABOUT THE AUTHOR March 13-16, Toronto, Ontario. Gordon Johnson is a leading attorney, advocate moreoninformation, visit and For author brain injury. is a 1979 cum

laude graduate of the University of Wisconsin law November school and a journalism grad from Northwestern University. He has authored some of the most6 -read webACRM pages Annual in brainConference, injury. He is the 8: 96th Past Chair of the Traumatic Brain Injury LitiNovember 6-8, Chicago, Illinois. gation Group, American Association of Justice. information, visit He For was more 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.

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. 1-800-53-LEGAL Follow Us: 993 Lenox Drive, Lawrenceville, NJ 08648

BRAIN INJURY professional 19

What Families, Clinicians and Payors Need to Know About Transitional Rehabilitation Gary S. Seale, PhD • Nicholas J. Cioe, PhD • Susan H. Connors

When a person sustains a traumatic brain injury (TBI), he and his family are thrust into a health care system that is unfamiliar and difficult to navigate. Too often, patients do not have access to the full continuum of treatment – especially transitional rehabilitation (TR). This article addresses why that is so and ways to change it.

Transitional Rehabilitation Defined TR is a program of comprehensive, residential treatment that includes intensive physical, cognitive, and behavioral therapies plus counseling, education, and medical care as needed (Chua et al., 2007). TR encompasses remediation techniques to restore function along with compensatory strategies, assistive technology, and environmental modifications to improve function. TR is sometimes called residential rehabilitation or transitional living because patients may reside in structured facilities that mimic real-world settings. TR is appropriate for individuals who have completed acute hospitalbased rehabilitation, are medically stable, and able to participate in intensive therapy. TR is also suitable for patients who may not have received acute rehabilitation or cannot safely transition from hospital to home due to increased risk for medical complications or re-injury. TR patients may have moderate to severe brain injuries and accompanying decrements in strength, poor balance, or decreased ability to perform basic activities of daily living (ADLs). Individuals who demonstrate post-traumatic amnesia, behavioral dysregulation, impulsivity, and poor self- and safety awareness are appropriate for TR programs, as are those who experience a change in life circumstances, such as the loss of a family caregiver or emergence of a secondary health condition. TR may also benefit patients with milder injuries or post-concussive disorders that do not respond to established treatment regimens.

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TR Differs from Other Treatment Unlike acute hospital-based rehabilitation, TR programs are community-based. Skills and strategies taught in the clinic are practiced in community venues to encourage self-awareness and self-reliance. Therapy, which can last up to eight hours per day, focuses on resuming former social roles and on mastering advanced ADLs. With proper safety measures in place, patients are allowed to make mistakes based on poor judgement, poor self-awareness, or poor impulse control to gain insight, refine goals, and enhance collaboration with the treatment team. TR programs address the individual’s ongoing medical needs, such as seizures, endocrine dysfunction, sleep disorders, pain, or swallowing disorders prior to discharge home. Ideally, the physician providing medical care is a specialist in brain injury medicine, such as a physiatrist. With the assistance of therapists or nurses, patients learn to arrange medical appointments, manage co-morbidities and medications, and practice the use and care of durable medical equipment. TR programs also guide families in making home modifications and learning behavior management techniques prior to discharge.

Challenges in Accessing TR About 52% of individuals age 15 and older with moderate to severe traumatic brain injury (TBI) are discharged directly home from an acute hospital with no further treatment (Cuthbert et al., 2011). Research suggests up to 20% of those with a severe injury return to pre-injury functioning within one year post-injury. Therefore, it is reasonable to believe there are several factors beyond spontaneous recovery that explain a premature departure from treatment.

Families simply do not know TR exists or how to advocate for admission to a TR program. TR programs may not be available in a particular geographic region. Clinicians do not refer patients because they misjudge the patient’s ability to make further gains or are unaware of the provider expertise, treatment intensity, and outcomes achieved at the post-acute level. Sometimes clinicians are pressured to discharge patients to less intensive placements, such as skilled nursing facilities, or are prohibited from discussing discharge options without prior clearance from payors. Additionally, some referrals are not made because the TR program is not in network, either a hospital network or payor network of providers. Payors control patient access to TR based on their coverage philosophies and payment policies. Those with long-term responsibility for the patient – such as workers compensation carriers – tend to invest in rehabilitation that maximizes a person’s health and independence. Payors with short-term responsibility – such as group health plan insurers – tend to stint on care, thereby shifting costs to families and public programs. Even payors that cover TR may deny admission based on medical necessity or may discontinue treatment due to lack of measurable progress. This short-sighted strategy may save money initially but can result in higher long-term costs due to re-hospitalization or the development of medical or psychosocial complications requiring treatment.

Clinicians Fight for Patients Clinicians can stop the harmful ‘delay, deny, discontinue, and discharge to daytime TV’ spiral that patients experience by clearly describing their patient’s on-going medical conditions and the physical and cognitive impairments that prevent a safe transition to home. Clinicians can articulate the benefits of appropriate treatment intensity and duration to ensure successful reintegration into the community (Tsaousides and Gordon, 2009). They can describe for payors the role of cognitive rehabilitation therapies in reducing activity limitations and participation restrictions (Malec and Basford, 1996) and the cost efficiencies and improved health outcomes achieved through comprehensive rehabilitation of sufficient scope, duration, timing, and intensity (Ashley and Cervelli, 2010).

Best Practices for Payors Payors benefit when they comprehend the differences in focus and philosophy across the TBI treatment continuum and the necessary variations in therapy intensity and duration to ensure successful return to the community. Similarly, payors benefit when they acknowledge that comprehensive-holistic treatment is the standard of care following TBI (Tsaousides and Gordon, 2009) because it reduces psychosocial problems and promotes community re-integration and return to work (Geurtsen et al., 2010), and can reduce lifetime costs. TR programs are particularly effective when therapies are implemented by an interdisciplinary team, using community-based rehearsal, cognitive rehabilitation therapy, and family involvement (Turner-Stokes, 2008). Payors benefit when they appreciate the difference between progress and outcome measurement at the acute and post-acute levels of care. Most hospital-based programs use the Functional Independence Measure (FIM) as the primary outcome measure. The FIM, has ceiling effects and is not appropriate for patients in TR programs (Hall et al., 2001). TR programs are focused on the overall functioning of the individual in real-world settings, and a larger range of outcomes are possible, such as return to productive activities, driving, and quality of life.

Therefore, most TR programs employ measures of global function, such as the Mayo-Portland Adaptability Inventory, and other measures important at the post-acute level of care, such as life satisfaction, mood, and supervisory need. Finally, payors benefit most when they embrace the substantial lifetime cost savings associated with participation in TR programs (Ashley et al., 1990 & 1993; Khan et al., 2002). These savings are most salient with regard to attendant care, development of medical and psychosocial complications, and avoidance of re-hospitalization.

Selecting a TR Program One of the most important decisions families make is where to obtain treatment for their loved ones. Regrettably, families often make decisions about placement based on marketing brochures rather than outcomes data. Choosing a TR program based on proximity to the family can be a mistake. Similarly, focusing only on the environment without asking questions about the program itself can lead to bad decisions. When selecting a TR program, families should determine how the facility is licensed and if the program uses best practices and evidenced-based clinical guidelines, or has earned accreditation (e.g., CARF, Joint Commission). They should investigate staff qualifications, organizational training culture, and staff to patient ratios. Top TR programs provide coordinated, interdisciplinary treatment by licensed physical, occupational, speech, music, and recreation therapists as well neuropsychologists, counselors, and case managers. Medical and nursing services are integrated into TR treatment and generally involve physiatrists, neurologists, and registered nurses. Residential programs provide up to 24/7 supervision by qualified staff, such as a certified medication assistant, certified nursing assistant, or certified brain injury specialist. Also available in top TR programs is around the clock access to a physician and neuropsychologist to avert medical or psychological crises. TR programs incorporate person-centered principles into treatment plans, and the family is integrated into the treatment team (e.g., involved with goal-setting, participate in therapy sessions, regularly visit the patient). Families will want to inquire about the balance between individual and group therapies, the number of therapy hours per day, and how free time is used. They should ask about the availability of peer support, family training, and help with transition planning, including vocational options and day programs. Above all else, families will want to know how patients with brain injuries of similar type and severity performed in the TR program.

Conclusion While hospital-based surgical and medical treatment saves a person’s life, transitional rehabilitation often places an important role in making that life worth living. The evidence for TR’s efficiency and long-term cost savings is substantial (Ashley & Cervelli, 2010), but too often payors dictate access to care, length of stay, and clinical services provided. We urge families and clinicians to advocate for improved insurance coverage of TR because it maximizes health outcomes and personal independence. Authors Note: We use the term “patient” throughout this article to reflect our opinion that transitional rehabilitation is a type of medically necessary treatment that should be paid by health insurance carriers.

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References Ashley MJ and Cervelli L. Maximizing rehabilitation outcomes and cost efficiency following acquired brain injury. Brain Injury Source. 7: 10-21, 2010. Ashley MJ, Krych DK, Lehr RP. Cost-benefit analysis for post-acute rehabilitation of the traumatically brain injured patient. Journal of Insurance Medicine. 22: 156-161, 1990. Ashley MJ, Persel CS, Krych DK. Changes in reimbursement climate: Relationship among outcome, cost, and payor type in the post-acute rehabilitation environment. Journal of Head Trauma Rehabilitation. 8: 30-47, 1993. Chua KSG, Ng YS, Yap SGM, et al. A brief review of traumatic brain injury rehabilitation. Annals Academy of Medicine. 36: 31-42, 2007. Cuthbert JP, Corrigan JD, Harrison-Felix C, et al. Factors that predict acute hospitalization discharge disposition for adults with moderate to severe traumatic brain injury. Archives of Physical Medicine and Rehabilitation. 92:721-730, 2011.

Hall KM, Bushnik T, Lakisic-Kazazic B, et al. Assessing traumatic brain injury outcome measures for long-term follow-up of community-based individuals. Archives of Physical Medicine and Rehabilitation. 82: 367-74, 2001. Katz DI, Polyak M, Coughlan D, et al. Natural history of recovery from brain injury after prolonged disorders of consciousness: outcome of patients admitted to inpatient rehabilitation with 1-4 year follow-up. Prog Brain Res. 177:73–88, 2009. Khan S, Khan A, Feyz, M. Decreased length of stay, cost savings and descriptive findings of enhanced patient care resulting from an integrated brain injury programme. Brain Injury. 16: 537-554, 2002. Malec JF, and Basford JS. Postacute brain injury rehabilitation. Archives of Physical Medicine and Rehabilitation. 77: 198-207, 1996. Nakase-Richardson R, Whyte J, Giacino JT, et al. Longitudinal outcome of patients with disordered consciousness in the NIDRR TBI Model Systems Programs. J Neurotrauma. 29: 59–65, 2012. Tsaousides T, and Gordon WA. Cognitive rehabilitation following traumatic brain injury: Assessment to treatment. Mount Sinai Journal of Medicine. 76: 173-181, 2009.

Geurtsen GJ, van Heugten CM, Martina JD, et al. Comprehensive rehabilitation programmes in the chronic phase after severe brain injury: A systematic review. Journal of Rehabilitation Medicine. 42: 97-110, 2010.

Turner-Stokes L. Evidence for the effectiveness of multidisciplinary rehabilitation following acquired brain Canoeing at Vinland’s campus in Loretto, Minnesota injury: a synthesis of main two approaches. Journal of Rehabilitation Medicine. 40: 691-701, 2008.

drug & alcohol treatment for adults with disabilities

Author Bios

Gary S. Seale, PhD, is Regional Director of Clinical Services for the Centre for Neuro Skills. He received his doctoral degree in Rehabilitation Science from the University of Texas Medical Branch (UTMB) in Galveston. He is licensed in Texas as a Psychological Associate and Chemical Dependency Counselor and holds a clinical appointment at UTMB in the School of Health Professions – Department of Rehabilitation Science. He has worked exclusively in post-acute brain injury rehabilitation for over 27 years and has conducted research and published peer-reviewed articles on rehabilitation outcomes, the relationship between positive emotion and recovery ofCenter functionalprovides status following stroke,and and emergency preparedness for disabled populations. Vinland drug alcohol treatment for adults with

cognitiveCounseling disabilities, including traumatic injury, fetal alcohol Nicholas J. Cioe, PhD, is the Director of Rehabilitation at Assumption College in Worcester, MA. Hebrain is a graduate from the College of the Holy Cross and received his Masters and Doctoral degrees from Southern Illinois University – Carbondale. He is a Certified Rehabilitation Counselor and spectrum disorder and learning disabilities. We make all possible Certified Brain Injury Specialist Trainer. Dr. Cioe has worked at all levels in TR programs and continues to provide staff training and individual rehabilitation plan development in the post-acute sector. His research and publications on responsedeficits to disability and following brain injury, impaired self-awareness, accommodations forfocus cognitive individual learning styles. rehabilitation issues, and brain injury outcomes. Located in Loretto, Minnesota — just 20 miles west of Minneapolis.

Susan H. Connors is president and chief executive officer of the Brain Injury Association of America (BIAA). She was executive director of the National Association of State Head Injury Administrators from 2001 to 2005 and BIAA’s national director of state affairs from 1995 to 2001. She has served in advisory capacities and on expert panels for several federal agencies, universities, and nonprofit organizations and has authored numerous publications, position statements and articles. She has a bachelor’s degree in public communication from George Mason University.

(763)479-3555 •




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



Canoeing at Vinland’s main campus in Loretto, Minnesota

drug & alcohol treatment for adults with disabilities Vinland Center provides drug and alcohol treatment for adults with cognitive disabilities, including traumatic brain injury, fetal alcohol spectrum disorder and learning disabilities. We make all possible accommodations for cognitive deficits and individual learning styles. Located in Loretto, Minnesota — just 20 miles west of Minneapolis.

(763)479-3555 • BRAIN INJURY professional 23

Money, Management and Mergers: The Business Aspects of Post-acute ABI Neurorehabilitation Dexter W. Braff, MBA, MS, BA • Ted Jordan, MBA, BS • Nancy Weisling, BS One of management’s primary responsibilities is to continually seek out ways to improve the business and financial operations of the company. This, in turn, often has the added effect of increasing the value of the firm – even if the company has no immediate intention to sell. In this article, we “reverse-engineer” the relationship, using the fundamentals of valuation as a framework to identify some of the key strategies a post-acute acquired brain injury (ABI) neurorehabilitation company may wish to focus on to make it better, stronger, and yes, more valuable.

The Building Blocks of Value At its very core, the building blocks of value are profit, growth, and risk management. In fact, if one breaks down all the textbook valuation methodologies heard of in the past – notably capitalization (multiple) of earnings or discounted cash flow – all are firmly rooted in these fundamental elements. Before we delve into how management can impact these elements in a business, however, let us talk about what, to many, may seem conspicuously missing. That is, where does quality fit in? To be sure, it is not that quality does not matter – it does. But not to the extent that may be believed.

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That is because in most health care businesses, whether it is deserved or not, a basic level of quality is assumed. On a scale of one to ten, most patients take it on faith that quality is at least a nine (after all, the staff has all those medical credentials, the facility looks state-of-the-art, and despite the realities on the ground, they are under the impression that all medicine is already evidence based). Now we are not suggesting management should not strive for clinical excellence – the team probably would not have gotten into such a complex field as neurorehabilitation unless they possessed a passion for improving the lives of patients. It is just that it is extremely hard to accurately measure, contrast, and compare clinical outcomes, so from a patient’s, or their loved one’s perspective, quality is often more about patient experience (was the staff friendly; the food good; the room clean?). What’s more, to move from a nine out of ten on the perceived quality scale to a 9.5, it may not only be awfully expensive, it is often lost on referral sources and payers, who, often, want little more in terms of quality than to not get any complaints.

Now, please do not see this as cynical. Providing the highest levels of care, particularly to such a vulnerable population as those suffering from acquired neurological disorders, is laudable. It is just that in health care, from a business perspective, “very good” can compete quite well with “excellent”. And excellent, can be disproportionately, expensive. Now, back to those building blocks.

Profit Typically measured in earnings before interest, taxes, depreciation, and amortization (EBITDA), profit is the “return” that buyers get on their investment in an acquisition. Notably though, it is not profit that the team manages per se. Rather, it is the revenues and expenses that produce it.

Revenues and Growth Perhaps counterintuitively, when it comes to growing the top line, there can be good revenues and less good revenues – particularly in health care. For example, consider the implications of a reimbursement system that is marching inexorably from feefor-service to fee-for-outcome (CMS has set an ambitious goal of having 50% of reimbursement coming from these alternative payment models by 2019). Such a system demands innovative population health and coordinated care strategies that (a) deliver a comprehensive mix of services to (b) distinct populations over (c) geographic footprints that (d) mirror the coverage area of health systems, insurance companies, or employers. In the past, just being bigger was often good enough. But as health care evolves, amassing flags on a map that extend beyond the reach of the health systems, insurers, and employers that define it, just does not add what they used to. In a coordinated care environment, hospital systems, large physician groups, and increasingly, so-called “conveners” are now acquiring, contracting, or in some manner affiliating with proximal providers across the healthcare spectrum to then go at-risk with insurance companies, Medicaid, or Medicare managed care plans to manage the health care needs of their beneficiaries. The question, then, is where does ABI fit in such a system. Our sense is that with a combination of low underwriting predictability and high, life-time costs, neuro-rehab is likely to be a “carve-out” under these population health umbrellas. But that does not mean that innovative providers cannot develop global payment models at the individual patient level to fill this gap in coverage. So, rather than open new states to grow, might it be better to build an end-to-end solution from transitional care to long-term rehab? Not only does this approach fit neatly in an environment that increasingly values coordinated care, it can create real competitive advantage that can translate to real increases in patient volume. What’s more, such a strategy works well on the expense side of the ledger, as deep penetration in tight geographic footprints tends to be less expensive to operate and manage than a coast-to-coast empire.

Revenue Cycle Management One final thought on revenues. Absent a comprehensive, integrated, revenue cycle management (RCM) system, what looks like revenue often is not.

Whether it is improperly booking, or accounting for, ever-changing price schedules or negotiated payments, or overlooking all the boxes that must be checked to remain in compliance before a bill is submitted for payment, if a company does not have a strong RCM in place, revenues may be no more than an educated guess. Not only does good RCM enable management to better manage – and optimize – the company’s cash flow, it creates far more reliable financial statements that support greater access to debt and equity capital – and at better terms. Here is a quick trick to see how well a provider is doing here. Add up cash collections for a defined period – say, 12 months. Then divide this figure by the net revenues booked, adjusted for average days sale outstanding rounded to the nearest number of months (so if it typically takes 65 days to collect, the corresponding 12-month revenue period should begin two months earlier – 65 days rounded – than the cash figures). If the result is not close to 100%, the company may have an RCM problem.

Expenses Management already knows that the company should constantly be on the lookout for opportunities to change processes or implement technology to reduce costs without compromising the company’s value proposition. What health care providers typically get wrong, however, is assumptions regarding economies of scale. The classic thinking is that once fixed costs are covered, any additional “contribution margin” falls to the bottom line. The problem in health care, however, is that what often appears to be a fixed cost is really a “step-variable”. Like pure variable costs, step-variables vary with volume, but over larger “steps”. Consider billing and collections. Typically lumped into fixed costs, staffing requirements will change as volume increases. Maybe not for the first additional 30-40 patients. But, add a hundred patients and these costs will rise (while the “real” fixed costs – heat, light, and rent – stay the same). Why is this so important? Pity the operator who prices a contract assuming that a big chunk of these “incremental” revenues – even at a substantially discounted rate – will fall to the bottom line. They may for a while. But, add a biller, scheduler, or a middle-management supervisor, and those profits can turn to losses real fast.

Deploying Technology One of the primary ways to capture real economies of scale is to invest in technology to reduce variable or step variable costs – and increase contribution margin. For example, one of the selling points of robust, “end-to-end” revenue cycle management solutions is to create efficiencies and reduced staffing requirements. The problem is that, rather than grab those efficiencies right away, providers adopt the “we’ll-just-grow-without-adding-additional staff” approach. Although conceptually valid, rarely does it work – at least completely. Human nature as it is, employees tend to expand their workload, regardless of its “real” volume, to match the work day (that is why it is a rare employee that does not believe they are working at full capacity). So, when volume increases, employees who have not been “forced” to realize gains in productivity find the additional workload unmanageable. Difficult as it may be, the best way to capture these gains is to reduce staffing levels once the technology is fully implemented.

BRAIN INJURY professional 25

Real Estate If management is looking for a lower-risk, long-term investment that can appreciate and generate long-term income, real estate fits the bill. But, if the rationale is that it adds value beyond its appraisal amount, note that most buyers believe that they can generate a higher return by adding more capacity. Accordingly, they rarely want to tie up their limited dollars in bricks and mortar.

Growth Growth is almost always good, but to create incremental value, it must be (a) identifiable, (b) greater than market, (c) sustainable, and (d) institutionalized. All too often, sellers cannot articulate what they are doing specifically to grow, owing it to “quality and our reputation in the community”. Perhaps this is the case. However, if buyers cannot identify specific initiatives that can increase market share, like adding sales reps, opening new programs and services, securing contracts, or partnering with referring entities, they will owe it to market growth rather than a business-enhancing proactive strategy. Growth must be sustainable. One new contract is good. But if the company hasn’t experienced executive sales professional with a history of bringing in new agreements and a pipeline of new opportunities in the works, that is the kind of growth that can pay dividends long into the future. Lastly, when we visit companies, it is usually quite apparent when they have a culture of growth – an overarching management emphasis on market innovation and expansion. Such growth is almost “institutional” in nature. Buyers can just feel it – and then, comfortably build it into their value equations.

Risk In health care, perhaps the greatest contributor to risk is reimbursement – especially when one or two payor sources, contracts, or other payment relationships account for the bulk of a firm’s cash flow.

With such “concentration” risk, even modest cuts in reimbursement can have an immediate and profound impact on a firm’s profitability.

The Fault with Michigan No-Fault Herein lies a fundamental challenge in brain injury treatment. Even though it has been a dependable source of reimbursement for many years, the fact that many providers rely heavily on Michigan nofault insurance is a point of great exposure. Accordingly, firms that develop other payer sources – private insurance, employer groups, unions, and increasingly, Medicaid – insulate themselves from “stroke-of-the pen” risk that makes buyers nervous. Similarly, while limited or exclusive contract relationships can be extremely valuable and profitable, the downside is that large chunks of revenues can come – and go – with these agreements. Accordingly, we like to see contracts as part of a balanced “portfolio” of payer sources. Broadening our perspective, risk comes from the potential for sudden, hard to control, unfavorable developments. So, anything a provider can do to mitigate such occurrences improves both the sustainability – and value – of the business. That is why companies with a management infrastructure that does not rely on the primary shareholder are attractive; why lots of referral sources vs. just a few are preferred, why systematic oversight of billing and regulatory compliance reduces exposure to potentially catastrophic lapses in record-keeping and documentation, why reviewed, or better yet, audited financials increases the likelihood that the story your numbers are telling is not fiction. The above are just a few items ABI providers may consider to strengthen their firm. The larger point, however, is that if a strategy in some way touches on the fundamental elements of value – if it increases profits, creates identifiable, sustainable, and institutional growth, or reduces the risk profile of the business – it is probably a strategy worth evaluating, and perhaps implementing. So, think like a seller, even if you are not.

Author Bios Dexter W. Braff, MBA, MS, BA, received his Masters in Business Administration from the Katz School of Business, University of Pittsburgh, where he was the recipient of the Vincent W. Lanfear award for academic excellence. He received his Bachelors of Arts from Cornell University, and a Masters of Science from the University of Oregon. He has more than 30 years of experience in health care mergers and acquisitions, and founded The Braff Group, ranked by Thomson Reuters as one of the nation’s leading health care M&A advisory groups, in 1998. Ted Jordan, MBA, BS, received an MBA from Emory University and a BS Economics / BS Finance from the University of Florida. Prior to joining The Braff Group in 2010, Ted served as Vice President of Mergers and Acquisitions for The Mentor Network, and was a financial analyst at Legacy Securities Corp., a boutique investment banking firm in Atlanta. He has worked in the behavioral health sector for more than 20 years. Nancy Weisling, BS, earned here degree at Bradley University. She has more than 20 years of experience in the behavioral health sector having begun her career teaching special education and later moving on to manage group homes for individuals with intellectual or developmental disabilities. Immediately prior to joining The Braff Group, she was Vice President for Mergers & Acquisitions and Business Development for The Mentor Network.

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expert interview

with Dr. Mark Ashley Mark Ashley, ScD, CCC-SLP, CCM, CBIST, is President/CEO of Centre for Neuro Skills® (CNS), which has operated postacute brain injury rehabilitation programs since 1980. Dr. Ashley serves on the Board of Directors of the Brain Injury Association of America, and is an Emeritus Chair. He serves on the Board of Directors of the California Brain Injury Association. Dr. Ashley is an Adjunct Professor at the Rehabilitation Institute of the College of Education at Southern Illinois University. Dr. Ashley founded the Centre for Neuro Skills Clinical Research and Education Foundation, a non-profit research organization.

Mark Ashley ScD, CCC-SLP, CCM, CBIST Thank you Dr. Ashley for taking the time to answer some questions, which I think will be of great interest to readers of Brain Injury Professional. I know that your long-standing involvement with post-acute rehabilitation will provide some interesting and enlightening perspectives on where the field has come from and where it is going. Firstly, I would like to get your thoughts on how post-acute rehabilitation got its start and in particular, what were the drivers that created opportunities for transitional rehabilitation programs as well as long term specialized assisted living services for persons with acquired brain injury. The field began in 1977, as did my professional career, when Ed Breen of the Home Insurance Company approached faculty at Southern Illinois University. Patients with TBI were surviving the injury, remaining in hospital for months to years, developing hospital borne complications and having discharge options of nursing homes, locked psychiatric facilities, prisons, or poorly prepared family homes. He needed to reduce their levels of disability in order to reduce the lifetime cost for their care. It was a win-win, natural to the contractual obligation under workers’ compensation. In the over 40 years that you have been involved in post-acute rehabilitation for persons with ABI, how have you seen the field evolve? What do you consider the most important advances that have been made in that timeframe? I began work in this field at the age of 15, when my brother was returned to our family home in locked-in syndrome. The field began as an experiment where the textbook knowledge was that recovery was completed by 6 months post-injury. We had to prove every treatment we undertook made measureable change toward the goal of reducing disability and, therefore, cost. There were just a few programs in the early 1980s. By the ‘90s, many more had come into existence and, in some regions, post-acute transitional rehabilitation and specialized assisted living programs had become the standard of care for workers’ compensation and liability carriers, in particular. Today, there is little doubt that the work we do can be exceptionally effective in improving the long-term quality of life for patients who are fortunate enough to receive this level of treatment. In the early days, we treated people who were up to 24 years post injury, with very few under 5 years. Today, we regularly see patients within a few months of injury, if not several weeks.

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The outcomes are remarkably better. We see long-term return to work rates approaching 65% and long-term follow-up stability in well over 90% of all cases, with many improving further after discharge. So, the most important advances would have to be earlier treatment, avoidance of complications, higher levels of specialized health care surveillance, development of combination therapies, and recognition of TBI as a disease and disease accelerative. What differences do you see in our healthcare system versus other countries as related to provision of post-acute rehabilitation services realizing that there is great disparity in availability of such services for a variety of reasons across geographic locales? The U.S. and Great Britain led the way with this level of treatment with early program development. Countries with socialized medicine tended to keep these patients in hospitals for extremely protracted periods, having few other options. As health plans in the U.S. learned from workers’ compensation carriers and began to see the benefits to shorter hospitalization and further disability reduction, increasing plans provided coverage for our level of care. However, to be clear, there are no contractual obligations to do so. Rather, it is, once again, a financial incentive that motivates these carriers to reduce hospitalization costs and complications in favor of less expensive options such as our treatment with a higher percentage of dollars expended going directly to patient care as opposed to bricks and mortar costs. A few other countries have seen this level of care emerge in the last decade and include Canada and Australia. What are your opinions as to why there are such differences across geographic regions in this country in acceptance of and payment for post-acute rehabilitation services, in particular transitional rehabilitation, relative to third party commercial insurance coverage for same? Is this a problem with us as providers not knowing how to market to this group of payors or are there geographic differences in acceptance of such services for payment support? First, while many carriers share similarities in their names, they do not share corporate structures or contract languages. Some come together in associations and gain some mutuality therefrom, however, there are many different plans. Additionally, even the national carriers undertake contracting state by state because the laws by which their underwriting is governed vary similarly. So, we have had to go plan by plan, having the same discussions and negotiations.

There are few of us who have even tried, and there are some who have led as the low cost leader. “Tell me what you will pay and I will put together a program.” Obviously, this is not how medicine works. It should be, “Tell me what is the most effective treatment for the disease and tell me what it costs to provide it.” Of course, we have responded to the financial pressures of health care, in general, to do more with less. Rehabilitation is, by its nature, adaptive. The problem is that too few have actually studied what does and does not work best and have simply done what they could do with what they were paid. So, the science in our field is turned inward, rather than outward, truly focusing on a comprehensive and detailed understanding of how to properly dose which patients with which disease characteristics after TBI. TBI is likely a constellation of diseases rather than a unified disease. We need to treat it as such in our research. We need much better business, research and clinical collaboration if we hope to begin to unravel the mystery of diseases after TBI. Finally, we need to embrace the neuroscience that underlies the diseases of TBI and that of the treatments we have available to potentially deliver. Health plans view our licensure as problematic and equate it with custodial care. Health plans are written to specifically exclude custodial care. We have to convincingly convey that we are undertaking intensive medical rehabilitation in seemingly non-medical settings. These settings are to our work what a surgical suite is to a surgeon. A surgeon requires all the supports found in an operating room, and we, similary, use all of the supports in the TRR settings to provide enriched environments and facilitate controlled, environmental demand-inducing neuroplasticity. We also have to accept that health insurance is intended to provide financial protection for medical treatment costs. Unfortunately, when treatment turns from predominantly rehabilitative to predominantly custodial, we must be willing to acknowledge same in order to maintain credibility. In many parts of the country, access to transitional rehabilitation services is very limited and typically driven by workers’ compensation reimbursement. What can we do collectively as a field to improve access for such services? We need to “break bread” with our colleagues in the health plan industry. We share a common population of people needing us to come together. We need to understand what their motivations are and help them to understand what we can and cannot truly deliver. We need to speak plainly to ourselves about what we do and don’t do, and come clean about our differences. We need to understand the parlance of those who we would hope to provide this coverage so as to communicate better with them and learn to use their language, as we teach them our own. As pointed out within this issue of BIP, we need to educate our colleagues, patients and families about what is possible in recovery and necessary in disease management and disease mitigation after TBI so as to increase the demand from payors for such coverage. Finally, our field spends a great deal of time talking to itself. If we had all the answers, we would be much further than we are. We need to embrace other disciplines. One of the best pieces of advice given me by one of my major professors was to read outside my discipline. I have built a career having done so. There are champions within the health plan world waiting to be recruited to this fine effort. We need to find them. Realizing that the scope, intensity and quality of transitional rehabilitation programs can vary greatly, what do you see as the future for such programs and how do you feel the field should work cooperatively to improve the quality of services provided and work towards standardization of assessment and treatment approaches in this context?

My career has been spent studying and standardizing treatment approaches with an eye toward a goal of providing the same or better outcomes in five years’ time in half the time and with half the cost. We have already achieved this seemingly audacious goal a couple times in the four decades I have been doing this work. We will benefit by reducing the parochial nature of our field, and bringing better business minds to it. Our field is highly clinical and our business savvy, or lack thereof, is showing by virtue of the problems you have raised in this interview in an industry that is over 40 years old. Nearly every industry one could name has learned the benefits of collaboration and “co-opetition” via industry specific trade associations. It may be that we have too many different factions within our field resulting in a neutralization of our overall effect. However rosy-eyed, I think we would better serve our patients and ourselves if we were to come together under a unified tent. There is now reasonable support from both animal and human research literature that ongoing rehabilitation, when done correctly, can have positive effects on neuroplasticity as well as protective effects on maladaptive neuroplastic changes, the latter which can result in neurologic and functional decline as a person with an acquired brain injury ages. Can you briefly speak to this issue in the context of your experiences and recommendations in the longer term care of persons with more severe acquired brain injuries? Our focus should be increasingly on disease specification after TBI. Is TBI today as cancer was in the ‘60s? Is it one disease, or is it many? Second, long-term care must provide for the individual to do as much for themselves as they can, with regular stretch goals built into the process. The brain is a use it or lose it structure. So, the environment in which a person lives must extract from them everything they are capable of and induce them to continuously improve their capability. We have learned this in healthy aging. Third, people must be followed by clinicians with specialization in brain injury medicine. We must be vigilant for the development of sleep disorders, neuroendocrine complications, early psychiatric complications and maximize social engagement levels. Lastly, we must focus on what we are missing. Why do degenerative diseases occur more frequently after a TBI? The answer is clearly in the changed neurophysiology and neuroanatomy after brain injury and interaction with genomic variations brought to the injury. How do we reduce or normalize neuroinflammation, repair the blood-brain barrier function, induce neurogenesis, gliogenesis, angiogenesis, and synaptogenesis, and limit cellular senescence, as examples? And, how will we develop necessary clinical and demographic data lakes, embrace machine learning, engage artificial intelligence, augmented reality and robots to enhance our treatment and quality of life after injury? What do you think the potential is for multicenter collaborative research by post-acute care providers who are involved with transitional rehabilitation and for long term care? How important do you think such research is to the field? The potential is great. We have seen good work come from such endeavors. We collaborate with a number of Universities and post-acute care providers. The limiting factor is money. Many of the efforts undertaken, thus far, have been funded by the involved parties. Grant funding is increasingly difficult to come by, and to be clear, not many in our field have experience in securing grant funding. This work is crucial to the sustainability of our field. I fear the loss of our industry at the hands of healthcare reform.

BRAIN INJURY professional 29

We are a fragmented industry for all the wrong reasons and we are at grave risk of losing the knowledge we have gained and failing the very people we strive to serve if we fail to come together at this critical time. Shifting gears a bit, I would like to know your thoughts on how best to train and retain direct care staff in such programs. This is a question for the Almighty. And I, and many others, have been asking! The training is the easy part. The nearly impossible is the retention. This is the hardest work one can do, if done properly. I lived it, I did this work, I have taught it, and consequently, I understand the retention challenge. There is no more demanding work one can do, and no more rewarding. But, the reward doesn’t pay the bills. These are some of the lowest paid positions and for some of the hardest work. How important do you think having specialized brain injury medicine physicians and neuropsychologists is from a staffing perspective for programs engaged in transitional rehabilitation or long-term care of persons after more severe ABI? Some of our best rehabilitative contribution comes from knowing what not to do. Physicians and neuropsychologists who specialize in brain injury can provide this information as well as what to do. The paradigm shift to brain injury as a disease and as disease accelerative/causative strongly suggests an ongoing role for specialized medical follow over the long-term. Do you feel that payors have a grasp on the importance of employing specialized professionals in the context of ongoing rehabilitative intervention and the charges incurred for same? I believe that Mr. Braff, Mr. Jordan and Ms. Weisling said it best, specialization is lost on most patients and payors. Even families and patients can’t develop a mechanism for understanding what we do, so they look at brochures, furniture, cleanliness, countryside, or proximity and make decisions. Or, worse, they leave the decision to the person with the brain injury, who has even less capability to decide well. Yelp and Google reviews are exceptionally inappropriate in health care, in particular, in highly specialized care such as ours. Payors have no developed system or motivation to discern qualitative differences among treaters. Their systems are about reducing the dollars out the door while providing treatment their members need within the coverage limitations of the contract their members purchased. So, our best hope may be in finding the best placed champions to change the payor approach from within. They can and do develop such awareness and understanding, if approached properly.

Lastly, I’m sure that you would agree that all programs providing such care have experienced increasing costs relative to health insurance, Workers’ Compensation and staffing costs. Given that, do you believe that such programs can be financially viable in the long term? How do you feel we can keep up with the ever-increasing costs of practice which likely outweighs what we reasonably can request from payors relative to rate adjustments in any given year? First, one has to understand what is required to properly treat a given patient, or group of patients. Second, one has to cover the cost of providing that treatment and all ancillary costs. Third, one has to continually innovate to find the next treatment and/or operational efficiency. This means learning from other fields, other industries. It means challenging assumptions as to how to provide what treatment. It means identifying the treatments that really work and abandoning those that don’t actually contribute. It means joining forces with like-minded colleagues across our industry to effect cost reductions and savings and share operational data to identify best practices. As for our financial viability, there are tremendous headwinds for our industry related to healthcare reform and the relatively low priority given in healthcare for our services. The simple answer is that one has to anticipate the rising costs of doing business and build these into pricing for annual pricing adjustments and into longer term contracting which is often unchangeable for multiyear periods. Many companies in our space are operated by clinicians. My own business preparation was scant and, after 40 years, I have come to recognize that business is every bit the science that medicine is. To that end, our business viability depends upon our business acumen and savvy. My best recommendation is to embrace professionals in business and incorporate them into the operations of your company. Any other thoughts that you have to round out our discussion? One final thought, as we consider how we protect what we have achieved as a field and shepherd it into its next life, we need to be courageous enough to leave the past and lean into the future. We need to come together in ways we have not thus far if we are to serve those we wish to in the best manner we can. This must be selfless, and we must be brave. We must, we simply must. I appreciate your time as I am sure all the readers of Brain Injury Professional do as well. Thank you.

About the Interviewer Nathan Zasler, MD, is an internationally respected physician specialist in acquired brain injury (ABI) care and rehabilitation. He is CEO and Medical Director of the Concussion Care Centre of Virginia, an outpatient neurorehabilitation practice, as well as, Tree of Life, a living assistance and transitional neurorehabilitation program for persons with acquired brain injury in Richmond, Virginia. He is board certified in Physical Medicine and Rehabilitation and fellowship trained in brain injury, as well as, Brain Injury Medicine certified. Dr. Zasler is an Adjunct Professor of PM&R at VCU in Richmond, Virginia, as well as, an Adjunct Associate Professor of PM&R at the University of Virginia, Charlottesville, Virginia. He is a fellow of the American Academy of Disability Evaluating Physicians, and a diplomat of the American Academy of Pain Management. Dr. Zasler has lectured and written extensively on neurorehabilitation issues in ABI. He is active in national and international organizations dealing with acquired brain injury and neurodisability, serving in numerous consultant and board member roles including currently serving as Vice-Chairperson of IBIA.

30 BRAIN INJURY professional

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Product Update Nathan Zasler, MD

References External Trigeminal Nerve Stimulation for the Acute Treatment of Migraine: Open-Label Trial on Safety and Efficacy. Chou DE, Gross GJ, Casadei CH, Yugrakh MS. Neuromodulation. 2017 Oct;20(7):678-683. doi: 10.1111/ner.12623. Epub 2017 Jun 5. An Update on Non-Pharmacological Neuromodulation for the Acute and Preventive Treatment of Migraine. Puledda F, Goadsby PJ. Headache. 2017 Apr;57(4):685-691.

The original Cefaly unit

Cefaly is a non-drug, non-invasive neuro-modulatory treatment for migraine that has been FDA approved for a number of years. The original device was manufactured in Belgium and had three settings, one for acute treatment, one for prophylaxis and one for relaxation. When originally approved in the United States in 2014, the unit was marketed with only one setting which was the prevention or prophylaxis setting. It was FDA approved for use with 2 settings last year and the unit has been redesigned to avoid the need for contact with the scalp on the sides of the head. It is easy to use and the currently recommended treatment time is one hour for acute migraine treatment and 20 minutes daily for prevention/prophylaxis. The Cefaly unit cost will vary depending on the model. There are currently 3 models available one for prevention, one for acute treatment and one that has both settings with pricing of $349, $349 and $499, respectively with volume discounting for professional purchases. Electrode costs are $25 USD for 3 regular electrodes and $33 USD for 3 hypoallergenic electrodes. Each electrode can be used up to 20 times.

Central and Peripheral Neural Targets for Neurostimulation of Chronic Headaches. Leone M, Cecchini AP. Curr Pain Headache Rep. 2017 Mar;21(3):16. doi: 10.1007/s11916-017-0616-x. Review. Non-invasive Neuromodulation in Primary Headaches. Miller S, Matharu M. Curr Pain Headache Rep. 2017 Mar;21(3):14. doi: 10.1007/s11916-017-0608-x. Review. Non-invasive transcutaneous Supraorbital Neurostimulation (tSNS) using Cefaly device in prevention of primary headaches. PrzeklasaMuszyńska A, Skrzypiec K, Kocot-Kępska M, Dobrogowski J, Wiatr M, Mika J. Neurol Neurochir Pol. 2017 Mar - Apr;51(2):127-134. Noninvasive neurostimulation methods for migraine therapy: The available evidence. Schoenen J, Roberta B, Magis D, Coppola G. Cephalalgia. 2016 Oct;36(12):1170-1180. Transcutaneous Supraorbital Nerve Stimulation (t-SNS) with the Cefaly®Device for Migraine Prevention: A Review of the Available Data. Riederer F, Penning S, Schoenen J. Pain Ther. 2015 Oct 14. [Epub ahead of print] Neuromodulation of Electrically Induced Hyperalgesia in the Trigeminocervical System. Reindl C, Seifert F, Nickel F, Maihöfner C. Pain Pract. 2016 Jul;16(6):712-9. doi: 10.1111/papr.12320. Epub 2015 May 28.

Based on available studies this type of neuro-modulatory treatment can assist not only with migraine control but also reduction in medications being taken for same and improvement in quality of life. The device requires a prescription in the United States. The unit provides external trigeminal nerve stimulation via a self adhered electrode placed on the fore head over the supraorbital nerves. The device generates a very low energy magnetic field (i.e. less than an electric shaver) and provides micro-impulses through the electrode to the upper branch of the trigeminal nerves. The side effect profile has been found to be extremely low with any side effects being typically mild in nature and transient.

For further information contact Cefaly US, Inc. at e-mail or phone 203-309-5670. In Europe, contact Cefaly Technology at e-mail telephone number +3243676722.

32 BRAIN INJURY professional

The current Cefaly FDA approved model



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new books of interest Into the Gray Zone: a Neuroscientist Explores the Border Between Life and Death Author: Dr. Adrian Owen

Scribner, New York, New York (2017)

Traumatic Brain Injury: Rehabilitation, Treatment, and Case Management, Fourth Edition Edited by: Mark J. Ashley, David A. Hovda CRC Press, Philadelphia, PA (2017)

Heal Through the Power of Awareness Author: Dr. Dennis Murphey

CreateSpace Independent Publishing Platform (2017)

The Concussion Repair Manual: A Practical Guide to Recovering from Traumatic Brain Injuries Author: Dr. Dan Engle

Lifestyle Entrepreneurs Press; Reprint edition (2017)

34 BRAIN INJURY professional

Children’s Healthcare of Atlanta has CARF-accredited pediatric rehab services We offer: • CARF-accredited inpatient and day rehab services with specialty recognition in spinal cord system of care, brain injury specialty program and pediatric specialty program • Care for patients big and small, from birth to age 21 • Board-certified pediatric physiatrists • 28 private rooms • Therapy seven days a week • Day rehab program for follow-up care

For more information or to make a referral: 404-785-2274

Children’s Healthcare of Atlanta Three hospitals • 27 neighborhood locations 876,000+ patient visits per year BRAIN INJURY PROFESSIONAL

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• Technology-assisted therapy through our Center for Advanced Technology and Robotic Rehabilitation



Madison Schwartz, Stanford Law, Randall H. Scarlett, Randall A. Scarlett, Ronnie Pang, Olga Rios, Mary Anne Scarlett, and Brendan D. Nay.

SCARLETT LAW GROUP Scarlett Law Group is a premier California personal injury law firm that in two decades has become one of the state’s go-to practices for large-scale personal injury and wrongful death cases, particularly those involving traumatic brain injuries. With his experienced team of attorneys and support staff, founder Randall Scarlett has built a highly selective plaintiffs’ firm that is dedicated to improving the quality of life of its injured clients. “I live to assist people who have sustained traumatic brain injury or other catastrophic harms,” Scarlett says. “There is simply no greater calling than being able to work in a field where you can help people obtain the treatment they so desperately need.” To that end, Scarlett and his firm strive to achieve maximum recovery for their clients, while also providing them with the best medical experts available. “As a firm, we ensure that our clients receive both

the litigation support they need and the cutting-edge medical treatments that can help them regain independence,” Scarlett notes. Scarlett’s record-setting verdicts for clients with traumatic brain injuries include $10.6 million for a 31-year-old man, $49 million for a 23-year-old man, $26 million for a 7-year-old, and $22.8 million for a 52-year-old woman. In addition, his firm regularly obtains eight-figure verdicts for clients who have endured spinal cord injuries, automobile accidents, big rig trucking accidents, birth injuries, and wrongful death. Most recently, Scarlett secured an $18.6 million consolidated case jury verdict in February 2014 on behalf of the family of a woman who died as a result of the negligence of a trucking company and the dangerous condition of a roadway in Monterey, Calif. The jury awarded $9.4 million to Scarlett’s clients, which ranks as



415.352.6264 | FAX 415.352.6265

one of the highest wrongful death verdicts rendered in recent years in the Monterey County Superior Court. “Having successfully tried and resolved cases for decades, we’re prepared and willing to take cases to trial when offers of settlement are inadequate, and I think that’s ultimately what sets us apart from many other personal injury law firms,” observes Scarlett, who is a Diplomate of the American Board of Professional Liability Attorneys. In 2015, Mr. Scarlett obtained a $13 million jury verdict for the family of a one year old baby who suffered permanent injuries when a North Carolina Hospital failed to diagnose and properly treat bacterial meningitis that left the child with severe neurological damage. Then, just a month later, Scarlett secured an $11 million settlement for a 28-year-old Iraq War veteran who was struck by a vehicle in a crosswalk, rendering her brain damaged.