The Community Approach to Participation: Outcomes Following Acquired Brain Injury Intervention

Implementation of the strengths model of case management for people with a traumatic brain injury: a qualitative pre-implementation study

INTRODUCTION

People who sustain a traumatic brain injury (TBI) may have to live with permanent sequelae such as mental health problems, cognitive impairments, and poor social participation. The strengths-based approach (SBA) of case management has a number of positive impacts such as greater community integration but it has never been implemented for persons with TBI. To support its successful implementation with this population, it is essential to gain understanding of how the key components of the intervention are perceived within the organization applying the approach.

OBJECTIVES

Documenting the barriers and facilitators in the implementation of the SBA as perceived by potential adopters.

METHODS

A qualitative pre-implementation study was conducted using semi-structured interviews with community workers and managers of the community organization where the SBA is to be implemented. Data were analyzed using a deductive approach based on the Consolidated Framework for Implementation Research (CFIR).

RESULTS

The major barriers are associated with the intervention (e.g. adaptability of the intervention) and the external context (e.g. the impact of the pandemic). Perceived facilitators are mainly associated with the internal context (e.g. compatibility with current values).

CONCLUSION

The barriers and facilitators identified will inform the research team's actions to maximize the likelihood of successful implementation.

Rehabilitation outcomes at discharge from staged community-based brain injury rehabilitation: A retrospective cohort study (ABI-RESTaRT), Western Australia, 2011–2020

Objective

To evaluate change in functional independence, psychosocial functioning, and goal attainment at discharge from a slow-stream Staged Community-Based Brain Injury Rehabilitation (SCBIR) service in Western Australia, 2011–2020.

Methods

Retrospective cohort study of n = 323 adults with acquired brain injury (ABI) enrolled in a post-acute SCBIR service compared against a control cohort of n = 312 with ABI admitted to three non-rehabilitation programs. Outcome measures were the UK Functional Independence Measure and Functional Assessment Measure (FIM+FAM), Mayo Portland Adaptability Inventory-4 (MPAI-4), and Goal Attainment Scale. Change in FIM+FAM and MPAI-4 scores and predictors of goal attainment at discharge were evaluated using multilevel mixed-effects regression.

Results

Median SCBIR length of stay was 20.5 months. Rehabilitation clients demonstrated clinically significant functional gains at discharge, adjusted mean change = +20.3, p < 0.001 (FIM+FAM). Peak gains of +32.3 were observed after 24–30 months and clinically significant gains were observed 5 years post-admission. Individuals discharged ≤6 months had the smallest functional gains (+12.7). Small psychosocial improvements were evidenced at discharge, mean reduction = −2.9T, p < 0.001 (MPAI-4) but not clinically significant. 47% of rehabilitation clients achieved their goals at the expected level or higher at discharge. Compared to the control, rehabilitation clients evidenced significantly greater functional gains and psychosocial improvement but lower goal attainment. Significant predictors of goal attainment at discharge were >2 years since injury, higher cognitive function and higher emotional adjustment at admission.

Conclusions

Functional recovery after ABI is a gradual and ongoing process. SCBIR is effective for functional rehabilitation post-injury but can be improved to achieve clinically meaningful psychosocial improvement.

Effective long-term management of brachial plexus injury following surgery: What is needed from hand therapists' perspectives

INTRODUCTION

Traumatic, brachial plexus injuries (BPI) result represent a significant cost to the individual and society. Recovery involves multiple surgeries, takes years, and often results in permanent physical dysfunction. While the last couple of decades have seen advancements in surgical management, the BPI rehabilitation literature has not kept pace with these developments.

PURPOSE

We aim to explore the experience of public and privately employed hand therapists' in delivering effective long-term rehabilitation services to inviduals with BPI in Australia.

METHODS

An interpretative qualitative study. Two focus groups were conducted with Australian hand therapists' (n = 10). Data were analyzed using an inductive thematic approach.

RESULTS

Three key themes were generated from the data. The first theme 'Falling through the gaps: overlooked components of therapy for BPI' captures participants' thoughts on postinjury health care and rehabilitation services. The second 'Developing a therapeutic alliance: underpinned by time and trust' relates to the relationship building challenges and opportunities following trauma that will withstand the long-term recovery of individuals following BPI. The last theme, 'Factors required for professional development: knowledge and support,' considers the variation seen with these clients in relation to therapy needs and outcomes.

CONCLUSIONS

The findings of this study highlight the need to better equip hand therapists' skills and knowledge in responding to pain and psychological management post BPI. Our results reinforce the benefit of interdisciplinary models of care in the management of individuals with BPI.

Translation, Validation and Reliability Testing of Community Integration Questionnaire-Revised (CIQ-R) Malay Version: A Preliminary Study

The Community Integration Questionnaire-Revised (CIQ-R) is a self-report standardized instrument designed to assess an individual's degree of community integration. The aim of this study was to translate, validate and conduct a reliability test of the CIQ-R Malay version. The development involved the three phases of translation, content validation and cognitive interviewing, test-retest reliability and internal consistency of the CIQ-R Malay version. The Content Validity Index (CVI) showed perfect agreement between the panel experts. The Intra-class Correlation Coefficient (ICC) demonstrated a moderate to excellent level of test-retest agreement (ICC 0.72 to 0.93). The Total CIQ-R Malay version and Home Integration subscale showed good internal consistency, with values of Cronbach's alpha ranging from 0.81 to 0.90. The findings from the present study provided preliminary support for the psychometric properties of the CIQ-R Malay version as a valid and reliable instrument to be used in Malaysia.

Results of an occupational self-analysis program in people with acquired brain injury. A pilot study

Purpose: The aim of this study was to evaluate the benefits of an occupational self-analysis program in people with acquired brain injury (ABI) in the areas of subjective health perception and occupational participation.Material and Method: This study explored the benefits of an occupational self-analysis program in people with ABI. The intervention group comprised 7 participants; the control group included 5 participants. Outcomes were measured using the SF-36 Health Survey and the Role Checklist. The contents of solicited participant diaries and a focus group discussion were also analyzed.Results: Compared to the control group, the intervention group showed statistically significant improvements in the SF-36 energy/fatigue subscale. The qualitative analysis revealed that participants in the intervention group increased their occupational participation in activities of daily living (ADL), social involvement, and leisure.Conclusion: The program helped participants improve their health perception and increase their occupational participation through learning about their supports and barriers for engaging in meaningful activities.

What is Known About Transitional Living Services for Adults With an Acquired Brain Injury? A Scoping Review

Transitional living service (TLS) programmes for adults with an acquired brain injury are considered an important part of rehabilitation. However, considerable variability exists in the design and structure of these services, with limited research to guide the development of a programme based on best evidence. A scoping literature review was completed to answer the question ‘What is known about TLS programmes for adults with an acquired brain injury?’ Four electronic databases were systematically searched, followed by a grey literature search (from 1996 to 2015). 3183 articles were screened and 13 articles were included in the final review. Themes that emerged from the literature include the types of residents using TLS programmes, the subjective experience of residents and staff, intervention approaches, programme staffing, and programme outcomes. The research reviewed supports the use of TLS programmes to maximise functional independence and community integration of individuals with an acquired brain injury. Clinical practise recommendations were developed to help support implementation of TLS programmes based on best evidence, these included: to use multiple outcome measures, implement collaborative goal setting, support generalisation of skills learnt in the TLS to the home environment and for eligibility criteria for these programmes to include individuals across all phases of recovery.

Community integration questionnaire: Outcomes of people with traumatic brain injury and high support needs compared with multiple matched controls

OBJECTIVES

To determine level of community integration in adults with traumatic brain injury and high support needs (TBI-HSN) compared with multiple matched controls.

SETTING

Community setting, Victoria, Australia.

PARTICIPANTS

Adults with TBI-HSN living in the community (n = 61). Australian normative data (n = 1973) was used for matching purposes (1:4).

DESIGN

Matched analysis from people with and without TBI. Matching aimed to reduce variability expected from age, gender, metropolitan/rural residence and co-resident status.

MAIN MEASURES

Community Integration Questionnaire (CIQ): total and sub-scales of Home Integration, Social Integration and Productivity.

RESULTS

Matched analysis showed large effects favouring the general population, e.g. CIQ total scores were significantly different, F(1, 304) = 5.8, p < 0.0001. Conditional relative risk showed community-dwelling participants with TBI were 540-times more likely to report a poor CIQ total score compared to the general population.

CONCLUSION

Normative CIQ data has enabled meaningful comparisons of the community integration of adults with chronic TBI to the general population in Australia. Evidence makes clear with numeric precision that individuals with TBI and high support needs are much less integrated than their non-TBI counterparts despite living in the community for many years.

The Community Integration Questionnaire - Revised: Australian normative data and measurement of electronic social networking

BACKGROUND/AIM

Consideration of the relationship between meaningful participation, health and wellbeing underpins occupational therapy intervention, and drives measurement of community integration following acquired brain injury (ABI). However, utility of community integration measures has been limited to date by lack of normative data against which to compare outcomes, and none examine the growing use of electronic social networking (ESN) for social participation. This research had four aims: (i) develop and pilot items assessing ESN to add to the Community Integration Questionnaire, producing the Community Integration Questionnaire-Revised (CIQ-R); (ii) examine factor structure of the CIQ-R; (iii) collect Australian CIQ-R normative data; and (iv) assess test-retest reliability of the revised measure.

METHODS

SETTING

Australia.

PARTICIPANTS

A convenience sample of adults without ABI (N = 124) was used to develop and pilot ESN items. A representative general population sample of adults without ABI aged 18-64 years (N = 1973) was recruited to gather normative CIQ-R data.

DESIGN

Cross-sectional survey.

MAIN MEASURES

Demographic items and the CIQ-R.

RESULTS

The CIQ-R demonstrated acceptable psychometric properties, with minor modification to the original scoring based on the factor analyses provided. Large representative general population CIQ-R normative data have been established, detailing contribution of a range of independent demographic variables to community integration.

CONCLUSION

The addition of electronic social networking items to the CIQ-R offers a contemporary method of assessing community integration following ABI. Normative CIQ-R data enhance the understanding of community integration in the general population, allowing occupational therapists and other clinicians to make more meaningful comparisons between groups.

Accommodation Outcomes and Transitions Following Community-Based Intervention for Individuals with Acquired Brain Injury

Objectives: To explore living situation, support and participation outcomes of people with severe acquired brain injury (ABI) residing in either home-like or disability-specific accommodation settings, who were provided with 3 years of occupational therapy intervention based on the Community Approach to Participation (CAP).

To examine transitions for a subgroup whose accommodation and support model changed during this 3-year period and identify factors critical to this change.

Method: Forty-three participants who had sustained severe to extremely severe ABI, and were an average of 6.73 years post-injury, were provided with CAP intervention over a 3-year period. Living situation and support model, participation levels and accommodation transition data were collected at four time points.

Results: Participants were living in a range of home-like and disability-specific accommodation settings at baseline. The disability-specific accommodation group had mainly noncompensable injuries and required a significantly higher level of daily support at all four time points. They also received higher total hours of support, which averaged 170.83 hours per week at baseline and did not change significantly over the 3 years. In contrast, 86% of the participants residing in home-like settings had compensable injuries and received an average of 91.46 hours of support per week at baseline. This reduced to 70.97 hours per week over the 3-year intervention period, a change that was statistically significant.

Conclusion: It is possible to achieve accommodation transitions to more independent, home-like situations many years post-injury and regardless of injury severity. Home-like settings provide scope to adjust support along a continuum to reflect gains in independence, community integration and role participation that the fixed models and hours of support in disability-specific accommodation do not. Over time, these gains can flow into a significant reduction in hours of support.

Transitions and Brain Injury: A Qualitative Study Exploring the Journey of People with Traumatic Brain Injury

This qualitative study aimed to explore transitions from hospital to the home over a period of one year.

Methods and procedures: A longitudinal, phenomenological approach was employed and 18 individuals with severe traumatic brain injury, their family members and rehabilitation professionals were interviewed using semistructured interviews, when the person with brain injury was discharged from the ward, after 6 months and again after one year.

Results: Themes identified within the data included returning home, getting back to normal, moving forward and the role of rehabilitation in the transitional period. Further subthemes were also identified including issues of life-course disruption, self-identity, status and reconstruction.

Conclusions: Data suggested that access to rehabilitation programs employing individualised, contextual interventions following discharge to the home were integral in enabling the transition through to autonomy and independence. Consideration of issues of identity and status can enable a different and potentially important perspective on the experience of transitions for those with brain injury. Reclaiming personal autonomy and control appeared to be central to the reconstruction of a coherent sense of self, enabling a meaningful life after brain injury.

Changes in Care and Support Needs Following Community-Based Intervention for Individuals With Acquired Brain Injury

Objective:To examine the care and support and participation outcomes for individuals with severe Acquired Brain Injury (ABI) provided with three consecutive years of Community Approach to Participation (CAP) intervention.Method:A case series study design was undertaken with a total of 43 participants from two private occupational therapy practices specialising in community-based, CAP rehabilitation for people with severe ABI. Data were collected at four time points: January 2004 (Baseline), January 2005 (T1), January 2006 (T2), and January 2007 (T3) and included rating on the Care and Needs Scale (CANS); number of hours of paid and gratuitous weekly support; FIM™ and Community Integration Questionnaire scores; and number of current life roles (as recorded on Part 1 of the Role Checklist). Participants were an average of 6.73 years post injury and were living in a range of community environments and residential facilities.Results:There was considerable change in participants' CANS rating across the intervention period, with statistically significant decreases occurring from Baseline to T1 and T1 to T2. Ninety-five per cent of participants received some level of weekly paid support throughout the intervention period, with the amount varying considerably. Paid care decreased by an average of 10.78 hours per week from 85.85 hours per week at Baseline to 75.06 at T3. Although not statistically significant, this equated to an average cost saving of AU$324.84 per participant per week by the end of CAP intervention. There was an overall mean reduction of 4.96 hours of gratuitous care per week per participant over the intervention period, which was statistically significant. Increases in functional independence, community integration, and role participation were also found. On the FIM™, statistically significant improvement occurred between Baseline and T1 and on the CIQ between Baseline and T1 and T1 and T2. Significant increase on the Role Checklist occurred between Baseline and T1 and between T2 and T3. The number of life roles in which participants engaged increased by an average of 1.65 roles by the end of the intervention period. A reduction in care and support needs (measured by the CANS) was significantly associated with: (1) a reduction in total care hours, (2) and an increase in functional independence on the FIM™, and (3) an increase in community integration on the CIQ.Conclusion:With a long term approach and contextualised intervention targeted at skill development in the areas that underpin personally valued participation, increased role performance and community integration can be achieved by people with severe ABI, even many years post injury. This increased capacity has been found to be associated with a reduction in care and support needs, including paid and gratuitous care hours, over time.

Moving from aged care facilities to community-based accommodation: outcomes and environmental factors

OBJECTIVE

Nearly 3500 people under 60 years of age are living in residential aged care in Australia, a situation which is generally recognized as incompatible with optimum quality of life. The objective of the current study is to explore the transition experiences of young people with acquired brain injury who have lived in aged care facilities and moved into community-based settings.

RESEARCH DESIGN

Grounded theory, qualitative design.

METHODS AND PROCEDURES

Semi-structured interviews were conducted with seven individuals with very severe ABI, seven family caregivers and two disability support workers. Each interview was recorded and transcribed verbatim.

RESULTS

Participants identified a range of positive outcomes that resulted from the transition from aged care settings to community living environments including increased independence in everyday activities, improved well-being and a greater degree of social inclusion. Participants also identified environmental factors that they deemed as crucial to facilitating positive outcomes.

CONCLUSIONS

People with very severe ABI have the potential to increase their level of independence in community-based accommodation settings; a potential that is not fostered in most aged care environments. The findings inform the outcome variables and environmental factors that should be measured in studies of transition from aged care to the community.

Young people in aged care: progress of the current national program

Objective. The aim of this paper is to examine the progress and effect of the current 5-year $244 million national Young People in Residential Aged Care program on the reduction of young people in aged care. Method. Semi-structured telephone interviews with 20 service providers, 10 advocacy organisations and 6 public servants across Australia actively involved in the implementation of the program. Results. The development of new accommodation options has been slow. The 5-year program aims to move 689 young people out of nursing homes; in the first 4 years of the initiative only 139 people had moved out. The lives of those who have been helped by the program have been enormously improved. Conclusions. This study highlights the challenges of achieving a long-term reduction in the number of young people in residential aged care, including the challenge of achieving systemic change to prevent new admissions. Implications. The accommodation options currently being developed for this target group will soon be at capacity. Without sustained investment in developing alternative accommodation options and resources to implement systemic change ~250 people under 50 are likely to continue to be admitted to aged care each year in Australia. What is known about the topic? Prior to the current 5-year, $244 million, national Young People in Residential Aged Care program there were more than 1000 Australians under 50 years of age who lived in aged care facilities. Aged care is not designed or resourced to facilitate the active involvement of young people with high clinical needs in everyday activities or support their continued participation in the life of their community. What does this paper add? In the first 4 years of the national program only 139 people moved out of aged care. The lives of those who have been helped by the program have been enormously improved. The program is unlikely to result in a long-term reduction in the number of young people in aged care. What are the implications for practitioners? Systemic change and sustained investment in accommodation options is required to resolve the issue of young people in aged care.