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Hou Y, Zhou A, Brooks L, Reid D, Turkstra L, MacDonald S. Rehabilitation access for individuals with cognitive-communication challenges after traumatic brain injury: A co-design study with persons with lived experience. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2024; 59:648-664. [PMID: 37189286 DOI: 10.1111/1460-6984.12895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/21/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Adults with traumatic brain injuries (TBI) frequently experience cognitive, emotional, physical and communication deficits that require long-term rehabilitation and community support. Although access to rehabilitation services is linked to positive outcomes, there can be barriers to accessing community rehabilitation related to system navigation, referral processes, funding, resource allocation and communications required to ensure access. AIMS This study aimed to identify barriers to accessing insurer funding for rehabilitation and healthcare services, for adults with TBI injured in motor vehicle collisions (MVCs). METHODS We used a co-design approach to collaborate with persons with lived experience to design a survey of adults who sustained a TBI in an MVC. The survey examined access to insurer funding for rehabilitation services and was disseminated through brain injury networks in Ontario, Canada. RESULTS Respondents (n = 148) identified multiple barriers to accessing rehabilitation services through insurer funding, including delays of more than 2 years (49%), mandatory duplicative assessments (64%) and invasion of privacy (55%). Speech-language therapy and neuropsychological services were denied most frequently. Negative experiences included insurers' poor understanding of TBI symptoms, denials of services despite medical evidence demonstrating need and unsupportive insurer interactions. Although 70% of respondents reported cognitive-communication difficulties, accommodations were rarely provided. Respondents identified supports that would improve insurer and healthcare communications and rehabilitation access. CONCLUSION & IMPLICATIONS The insurance claims process had many barriers for adults with TBI, limiting their access to rehabilitation services. Barriers were exacerbated by communication deficits. These findings indicate a role for Speech-language therapists in education, advocacy and communication supports during the insurance process specifically as well as rehabilitation access processes in general. WHAT THIS PAPER ADDS What is already known on this subject There is extensive documentation of the long-term rehabilitation needs of individuals with traumatic brain injury (TBI) and their challenges in accessing rehabilitation services over the long term. It is also well known that many individuals with TBI have cognitive and communication deficits that affect their interactions in the community, including with healthcare providers, and that SLTs can train communication partners to provide communication supports to individuals with TBI in these communication contexts. What this study adds This study adds important information about barriers to accessing rehabilitation, including barriers to accessing SLT services in the community. We asked individuals with TBI about challenges to accessing auto insurance funding for private community services, and their responses illustrate the broader challenges individuals with TBI face in communicating their deficits, conveying service needs, educating and convincing service administrators and self-advocating. The results also highlight the critical role that communication plays in healthcare access interactions, from completing forms to reviewing reports and funding decisions, to managing telephone calls, writing emails and explaining to assessors. What are the clinical implications of this work? This study shows the lived experience of individuals with TBI in overcoming barriers to accessing community rehabilitation. The results show that best practices in intervention should include evaluating rehabilitation access, which is a critical step in patient-centred care. Evaluation of rehabilitation access includes evaluating referral and navigation, resource allocation and healthcare communications, and ensuring accountability at each step, regardless of model of service delivery or funding source. Finally, these findings show the critical role of speech-language therapists in educating, advocating and supporting communications with funding sources, administrators and other healthcare providers.
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Affiliation(s)
- Yvette Hou
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Aileen Zhou
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Laura Brooks
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Daniella Reid
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Lyn Turkstra
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Sheila MacDonald
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
- Sheila MacDonald & Associates, Guelph, Ontario, Canada
- Department of Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada
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Young MJ. Disorders of Consciousness Rehabilitation: Ethical Dimensions and Epistemic Dilemmas. Phys Med Rehabil Clin N Am 2024; 35:209-221. [PMID: 37993190 DOI: 10.1016/j.pmr.2023.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Patients with disorders of consciousness who survive to discharge following severe acute brain injury may face profoundly complex medical, ethical, and psychosocial challenges during their courses of recovery and rehabilitation. Although issues encountered in caring for such patients during acute hospitalization have received substantial attention, ethical challenges that may arise in subacute and chronic phases have been underexplored. Shedding light on these issues, this article explores the landscape of normative issues in the course of treating and facilitating access to care for persons with disorders of consciousness during rehabilitation and examines potential implications for patients, clinicians, family members, and society.
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Affiliation(s)
- Michael J Young
- Department of Neurology, Massachusetts General Hospital, Center for Neurotechnology and Neurorecovery, 101 Merrimac Street, Suite 310, Boston, MA 02114, USA.
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Walker WC, Perera RA, Hammond FM, Zafonte R, Katta-Charles S, Abbasi KW, Hoffman JM. What Are the Predictors for and Psychosocial Correlates of Chronic Headache After Moderate to Severe Traumatic Brain Injury? J Head Trauma Rehabil 2024; 39:68-81. [PMID: 38032830 DOI: 10.1097/htr.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
OBJECTIVE Although headache (HA) is a common sequela of traumatic brain injury (TBI), early predictors of chronic HA after moderate to severe TBI are not well established, and the relationship chronic HA has with psychosocial functioning is understudied. Thus, we sought to (1) determine demographic and injury predictors of chronic HA 1 or more years after moderate to severe TBI and (2) examine associations between chronic HA and psychosocial outcomes. SETTING Community. PARTICIPANTS Participants in the TBI Model System (TBIMS) with moderate to severe TBI who consented for additional chronic pain questionnaires at the time of TBIMS follow-up. DESIGN Multisite, observational cohort study using LASSO (least absolute shrinkage and selection operator) regression for prediction modeling and independent t tests for psychosocial associations. MAIN OUTCOME MEASURES Chronic HA after TBI at year 1 or 2 postinjury and more remotely (5 or more years). RESULTS The LASSO model for chronic HA at 1 to 2 years achieved acceptable predictability (cross-validated area under the curve [AUC] = 0.70). At 5 or more years, predictability was nearly acceptable (cross-validated AUC = 0.68), but much more complex, with more than twice as many variables contributing. Injury characteristics had stronger predictive value at postinjury years 1 to 2 versus 5 or more years, especially sustained intracranial pressure elevation (odds ratio [OR] = 3.8) and skull fragments on head computed tomography (CT) (OR = 2.5). Additional TBI(s) was a risk factor at both time frames, as were multiple socioeconomic characteristics, including lower education level, younger age, female gender, and Black race. Lower education level was a particularly strong predictor at 5 or more years (OR up to 3.5). Emotional and participation outcomes were broadly poorer among persons with chronic HA after moderate to severe TBI. CONCLUSIONS Among people with moderate to severe TBI, chronic HA is associated with significant psychosocial burden. The identified risk factors will enable targeted clinical screening and monitoring strategies to enhance clinical care pathways that could lead to better outcomes. They may also be useful as stratification or covariates in future clinical trial research on treatments.
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Affiliation(s)
- William C Walker
- Departments of Physical Medicine and Rehabilitation (Dr Walker and Ms Abbasi) and Biostatistics (Dr Perera), School of Medicine, Virginia Commonwealth University, Richmond; Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine & Rehabilitation Hospital of Indiana, Indianapolis (Drs Hammond and Katta-Charles); Spaulding Rehabilitation Network, Boston, Massachusetts (Dr Zafonte); Massachusetts General Hospital & Brigham and Women's Hospital, Boston (Dr Zafonte); Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts (Dr Zafonte); and Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Dr Hoffman)
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Lercher K, Kumar RG, Hammond FM, Zafonte RD, Hoffman JM, Walker WC, Verduzco-Gutierrez M, Dams-O’Connor K. Distal and Proximal Predictors of Rehospitalization Over 10 Years Among Survivors of TBI: A National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems Study. J Head Trauma Rehabil 2023; 38:203-213. [PMID: 36102607 PMCID: PMC9985661 DOI: 10.1097/htr.0000000000000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the rates and causes of rehospitalization over a 10-year period following a moderate-severe traumatic brain injury (TBI) utilizing the Healthcare Cost and Utilization Project (HCUP) diagnostic coding scheme. SETTING TBI Model Systems centers. PARTICIPANTS Individuals 16 years and older with a primary diagnosis of TBI. DESIGN Prospective cohort study. MAIN MEASURES Rehospitalization (and reason for rehospitalization) as reported by participants or their proxies during follow-up telephone interviews at 1, 2, 5, and 10 years postinjury. RESULTS The greatest number of rehospitalizations occurred in the first year postinjury (23.4% of the sample), and the rates of rehospitalization remained stable (21.1%-20.9%) at 2 and 5 years postinjury and then decreased slightly (18.6%) at 10 years postinjury. Reasons for rehospitalization varied over time, but seizure was the most common reason at 1, 2, and 5 years postinjury. Other common reasons were related to need for procedures (eg, craniotomy or craniectomy) or medical comorbid conditions (eg, diseases of the heart, bacterial infections, or fractures). Multivariable logistic regression models showed that Functional Independence Measure (FIM) Motor score at time of discharge from inpatient rehabilitation was consistently associated with rehospitalization at all time points. Other factors associated with future rehospitalization over time included a history of rehospitalization, presence of seizures, need for craniotomy/craniectomy during acute hospitalization, as well as older age and greater physical and mental health comorbidities. CONCLUSION Using diagnostic codes to characterize reasons for rehospitalization may facilitate identification of baseline (eg, FIM Motor score or craniotomy/craniectomy) and proximal (eg, seizures or prior rehospitalization) factors that are associated with rehospitalization. Information about reasons for rehospitalization can aid healthcare system planning. By identifying those recovering from TBI at a higher risk for rehospitalization, providing closer monitoring may help decrease the healthcare burden by preventing rehospitalization.
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Affiliation(s)
- Kirk Lercher
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai
| | - Raj G. Kumar
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai
| | - Flora M. Hammond
- Department of Physician Medicine and Rehabilitation, Indiana University School of Medicine and Rehabilitation Hospital of Indiana, Indianapolis, Indiana
| | - Ross D. Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeanne M. Hoffman
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, WA
| | - William C. Walker
- Dept. of Physical Medicine and Rehabilitation (PM&R), School of Medicine, Virginia Commonwealth University (VCU), Richmond, VA
| | - Monica Verduzco-Gutierrez
- Department of Rehabilitation Medicine, Long School of Medicine at UT Health San Antonio, San Antonio, Texas
| | - Kristen Dams-O’Connor
- Brain Injury Research Center, Professor, Department of Rehabilitation and Human Performance, Department of Neurology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1163, New York
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Schramm AT, Libby Schroeder ME, Brandolino AM, Kant JM, Kohlbeck SA, Bergner C, Milia DJ, deRoon-Cassini TA. Disparities in disposition from trauma centers to inpatient psychiatric treatment in a national sample of patients with self-inflicted injury. Surgery 2023; 173:799-803. [PMID: 36357230 DOI: 10.1016/j.surg.2022.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Surgery providers are integral to the treatment of patients with self-inflicted injuries. Patient disposition (eg, home, inpatient psychiatric treatment, rehabilitation) is important to long-term outcomes, but little is known about factors influencing disposition after discharge following traumatic self-inflicted injury. We tested whether patient or injury characteristics were associated with disposition after treatment for self-inflicted injury. METHODS National Trauma Data Bank query for self-inflicted injuries from 2010 to 2018. RESULTS There were 77,731 patients treated for self-inflicted injuries during the study period. Discharge home was the most common disposition (45%), and those without insurance were less likely to discharge to inpatient psychiatric treatment than those with insurance. Racial minority patients were less likely to discharge to inpatient psychiatric treatment (18.9%) than nonminority patients (23.8%, P < .001). Additionally, patients discharged to inpatient psychiatric treatment had significantly lower injury severity score (7.24 ± 7.5) than those who did not (8.69 ± 9.1, P < .001). CONCLUSION Racial/ethnic minority patients and those without insurance were significantly less likely to discharge to an inpatient psychiatric facility after treatment at a trauma center for self-inflicted injury. Future research is needed to evaluate the internal factors (eg, trauma center practices) and external factors (eg, inpatient psychiatric facilities not accepting patients with wound care needs) driving disposition variability.
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Affiliation(s)
- Andrew T Schramm
- Division of Trauma & Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI; Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WI.
| | - Mary E Libby Schroeder
- Division of Trauma & Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Amber M Brandolino
- Division of Trauma & Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jacey M Kant
- Division of Trauma & Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI; Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WI
| | - Sara A Kohlbeck
- Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WI
| | - Carisa Bergner
- Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WI
| | - David J Milia
- Division of Trauma & Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Terri A deRoon-Cassini
- Division of Trauma & Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI; Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WI
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Disparities in Chronic Pain Experience and Treatment History Among Persons With Traumatic Brain Injury: A Traumatic Brain Injury Model Systems Study. J Head Trauma Rehabil 2023; 38:125-136. [PMID: 36883895 DOI: 10.1097/htr.0000000000000870] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
OBJECTIVE To determine disparities in pain severity, pain interference, and history of pain treatment for non-Hispanic Whites, non-Hispanic Blacks, and Hispanics with traumatic brain injury (TBI) and chronic pain. SETTING Community following discharge from inpatient rehabilitation. PARTICIPANTS A total of 621 individuals with medically documented moderate to severe TBI who had received acute trauma care and inpatient rehabilitation (440 non-Hispanic Whites, 111 non-Hispanic Blacks, and 70 Hispanics). DESIGN A multicenter, cross-sectional, survey study. MAIN MEASURES Brief Pain Inventory; receipt of opioid prescription; receipt of nonpharmacologic pain treatments; and receipt of comprehensive interdisciplinary pain rehabilitation. RESULTS After controlling for relevant sociodemographic variables, non-Hispanic Blacks reported greater pain severity and greater pain interference relative to non-Hispanic Whites. Race/ethnicity interacted with age, such that the differences between Whites and Blacks were greater for older participants (for severity and interference) and for those with less than a high school education (for interference). There were no differences found between the racial/ethnic groups in the odds of having ever received pain treatment. CONCLUSIONS Among individuals with TBI who report chronic pain, non-Hispanic Blacks may be more vulnerable to difficulties managing pain severity and to interference of pain in activities and mood. Systemic biases experienced by many Black individuals with regard to social determinants of health must be considered in a holistic approach to assessing and treating chronic pain in individuals with TBI.
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