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Traumatic Brain Injury Rehabilitation: Case Management and Insurance-Related Issues
Phys Med Rehabil Clin N Am 18 (2007) 165–174
Traumatic Brain Injury Rehabilitation: Case Management and Insurance-Related Issues Helaine Tobey Pressman, MS, CCC/SLP-L, CBIT, CCM* Intracorp, 525 W. Monroe Street, Chicago, IL 60661, USA
Traumatic Brain Injury (TBI) cases are medically complex, involving the physical, cognitive, behavioral, social, and emotional aspects of the survivor. Often catastrophic, these cases require substantial financial resources not only for the patient’s survival but to achieve optimal outcomes for a functional life, including the return to family and work responsibilities for the long term. TBI cases involve the injured person, the family, medical professionals, treating physicians, therapists, attorneys, the employer, community resources and in most cases an insurance company. Case managers help to facilitate a successful return to family and work by collaborating with all parties, assessing priorities and options, coordinating services, and educating and communicating with all concerned. The case manager acts as health care and human services professional. He or she adheres to standards of privacy and confidentiality and handles all medical and jurisidictional issues in an ethical manner [1]. Ashley and colleagues [2] have discussed the positive relationship between effective case management and a productive clinical therapy program in a successful outcome for the patient who has TBI. A key component in achieving successful outcomes as a case manager of brain injury cases is to have a thorough knowledge of TBI. When managing TBI cases, it is important to discern not only the major deficits but also the subtleties of minor deficits that may not be apparent to the involved parties. These major deficits can impact the survivor’s future acquisition of lost skills and his or her success in achieving the necessary outcomes to be able to return to a healthy, functional, and productive life. * 390 Greenwood Avenue, Glencoe, IL 60022. E-mail address: [email protected] 1047-9651/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.pmr.2006.11.006 pmr.theclinics.com
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Insurance Case managers have learned how to navigate the ever changing managed care system. In the last twenty years medical costs have increased and treatments have changed. Insurance coverage and benefits also vary significantly from person to person because there are a multitude of companies and policies. In some cases a claimant may have a lifetime coverage limit. But it can be exhausted with one catastrophic injury costing over 1 million dollars. Some insurance policies have benefits for therapy (physical, occupational, and speech), home care, durable medical equipment, and attendant care, others do not. In an ideal situation where there are sufficient resources, the case manager works with the patient (survivor), family, physicians, therapists, attorneys, insurance company, and employer.
TBI case management issues When reviewing records for the initial evaluation in the hospital phase, it is necessary to review the emergency medical technician’s records at the site of injury. This review helps you understand the mechanism of injury [3,4] at the scene of the accident and loss of consciousness information. The patient typically does not remember the accident and may be in a stage of posttraumatic amnesia after the event. These types of responses are typically unreliable at this stage. The length of time the patient spends in this stage varies. The patient will probably not remember the hospitalization, but the family certainly will. Family involvement plays a key role in the patient’s recovery. Studies show that patients with strong family support fare better than their counterparts without support and family involvement positively affect outcomes [5]. During recovery, the patient’s perception of his or her abilities and deficits can vary greatly from the perceptions of others. Anosognosia, a lack of awareness, is common in persons with TBI. Questioning the family as to the actual abilities of the patient is important because the actual levels of ability are perceived differently by the patient and the family. It is important to share this information with the physician(s). A person with TBI often has several other injuries, making the case complex. There are often neurosurgical, neurologic, cognitive, communicative, orthopedic, visual, hearing, balance, and psychologic areas affected. With the multiple treating physicians and therapists, it is critical for the case manager to communicate information among this varied group. At first, the neurosurgeon may direct initial rehabilitation in the ICU and acute care phase. As the patient’s neurosurgical status stabilizes, care should be transitioned to the direction of the specialist in physical medicine and rehabilitation who has a strong background in TBI. Physicians generally have a short time to spend with the patient at each visit and may not be able to observe
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the patient in a prolonged, real life environment. It is important for the family to provide the physician with a true picture of the patient’s abilities and deficits. It is also very important for the case manager to communicate clinical information among all treating providers since there can be several. Additionally, coordination of care is critical. The patient may need surgery for one condition which may need to supersede treatment of another problem. The case manager coordinates communication between providers, thereby helping to optimize recovery of the patient. The role of the case manager in the continuum of care The case manager can receive a case at any phase in this continuum of care and recovery. Depending on the stage at which the case is received, different work may be needed. In some cases, when a case is received at a later stage in the continuum, the case manager may work with the physicians to determine if all necessary care and treatment were given to the patient. If it is determined that additional care was needed in an earlier stage, the injured person may need to go back for further care. This continuum of care is a general guide and the case manager will work to explain the guide to the insurance company to ensure that reserves are adjusted, if necessary, during the rehabilitation course. Hospital (ER, ICU, acute care) The initial referral to the case manager will include instructions to obtain the medical records, cause of injury, surgical information, and plan of care from the treating physician. Generally, the first task is to meet with the Utilization Review personnel at the hospital to obtain permission and information and to meet with the patient and family. In catastrophic cases, a trauma care coordinator acts as the hospital liaison with the case manager. The case manager explains his or her role in facilitating any necessary communication between the hospital and the insurance company. The case manager’s involvement is a mutually beneficial and cooperative because both parties need the assistance of the other in management of the case. The case manager meets with the patient to determine his or her status and to put the medical records into context. A visual meeting can tell him or her a lot about the status of the patient and puts the medical records into context when they are reviewed. The case manager also meets with the family to see how they are coping with the injury and explains his or her role in assisting with the care of their family member to evaluate the services needed and the options available to meet the injured person’s recovery needs. The case manager aims to build a rapport with the family and to elicit cooperation by explaining that he or she will be working with the family through the continuum of the recovery for the long-term. In cases where the claimant has suffered a work related injury, the case manager explains that the long-term goal is to facilitate their loved one to the point of recovery where he or she
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will be able to return to work. During this time in the care continuum it is important to remember that the family has just been through a traumatic event and emotions are running high. Attempt to keep the family focused on the positive and give them an end recovery goal to work toward. In most cases, when the patient emerges from coma, is able to respond to localized external stimuli (Rancho level 3) [6], and is medically stable, he or she is transferred to acute hospital care for a short period of time and then to inpatient rehabilitation. At the acute hospital phase, the case manager will encourage and assist the family in visiting the in-patient rehabilitation unit (units which specialize in treatment for TBI). The case manager helps prepare the family in advance so that they know what to expect when visiting the patient. As a person with TBI starts to ‘‘wake up,’’ he or she can become agitated and may become physically and verbally aggressive. This stage is referred to as Rancho Level 4-5 [6]. If the family is not prepared for this type of behavior it can be very disturbing. The case manager will explain that this behavior proves the patient is moving up the recovery scale and that the reason for agitation and aggressive behavior is due to the patient’s confusion and hypersensitivity to sound, light and touch. The Brain injury unit staff will manage these behaviors while keeping the patient safe by providing specialized treatment, controlled stimulation, a controlled environment and specialty equipment. The medical staff, along with the case manager, will educate the family about the brain injury and explain the patient’s needs so that when the family visits they will have an understanding of what the TBI unit provides. The case manager will help to put this information into context for the family and discuss future steps in the care continuum process. The case manager also updates the insurance company on the stages of progress across the care continuum. The case manager explains progress and the steps necessary for the patient to achieve a functional and productive life to ensure adjustments are made to the patient’s reserves as necessary. The end goal is always to assist the patient in recovery so that he or she may return to a productive lifestyle and in workers’ compensation cases in particular, to return the patient to the same job with the same employer. Sub-acute facilities Sub-acute facilities may exist as a unit in an acute care or rehabilitation hospital or in a nursing home. Patients are admitted to this type of facility if they are unable to sustain at least 3 hours of therapy per day. As their medical status improves, they are transferred to an inpatient rehabilitation hospital. The case manager will obtain updated information at least once a week at this level of care or more frequently depending on the patient’s medical status. Rehabilitation hospital (inpatient) At this level in the continuum of care, the injured person is physically able to participate in at least 3 hours of therapydphysical, occupational, and
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speech/cognitive/communicative/dysphagia (swallowing) therapy. A neuropsychologic evaluation is performed when the patient has sustained attention and concentration and can participate in a meaningful manner. If the patient is physically unable to participate for 3 hours a day, then he or she will be admitted to a subacute rehabilitation facility where the therapy demands are less. As the patient becomes stronger and more responsive, he or she can transfer to an inpatient rehabilitation unit. The case manager attends patient care conferences, usually on a weekly basis, with the rehabilitation team, obtaining medical and rehabilitation status and a time frame for discharge. The discharge location is important because the rehabilitation team needs to set goals with the patient (as possible) and his or her family. If the patient is to be discharged home, the family will need to be closely involved in the rehabilitation, participate in family teaching by the different therapists, and be able to understand the need for 24-hour supervision if necessary. Financial resources play an important role in determining the discharge site. The discharge planner in the hospital will assist the family in obtaining state and federal medical assistance if necessary. The discharge site may change again depending on the finances available. Home health care When the patient is able to be discharged to home, or in some cases, refuses to go to an inpatient facility and insists on returning home, home health services are often a good alternative. Home health services are often covered in medical insurance policies and many have specialized traumatic brain injury programs with therapists who can treat the injured person at home. A home based program can be an advantage in that the injured person is in a familiar setting and the rehabiliation is done in a functional, real-life environment. The case manager communicates separately with all therapists and the home health nurse because there is no team structure in a home based program. However, in a specialized program, the case manager coordinates team conferences where all team members are in communication with each other. Community re-entry program (residential and outpatient day program) Community re-entry programs are staffed by trans-disciplinary TBI rehabilitation teams which address the deficits in individual and group environments at home and in the community. The case manager attends regularly scheduled team conferences, usually on a monthly basis, with the rehabilitation team, including the injured person and his or her family members. Rehabilitation usually lasts for several months; vocational rehabilitation, if appropriate, is integrated into the program as early as possible. The case manager facilitates communication between the vocational specialist and the employer, incorporating the patient’s job description into the total rehabilitation program. During the community re-entry level of rehabilitation,
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the patient may feel frustration in dealing with the challenging rehabilitation. The case manager works with the patient to increase the complexity and duration of the rehabilitation as time goes on in order to approach the level of function the patient was able to perform pre-morbidly. During this time, the case manager attends all follow-up physicians’ appointments and communicates the patient’s rehabilitation status to the medical professionals and to the insurance company. TBI patients may also see a neurodevelopmental or behavioral optometrist to correct visual-perceptual and balance deficits through the use of specialized prism lenses and exercises. An evaluation by a neurodevelopmental and/or behavioral optometrist helps direct the physical and occupational therapists to assist the patient in performing specific and detailed exercises resulting in more functional outcomes than typical therapy alone. Prescription lenses also help to eliminate the visual-perceptual deficits without physical or occupational therapy intervention at all, depending on the individual patient. Skilled nursing facility In some cases, even after acute rehabilitation is complete, the patient may remain at a low functional level and not be able to return home. In this scenario the patient is admitted to a skilled nursing facility for long-term care. Lack of medical insurance for a specialized TBI rehabilitation facility can also cause the patient to be admitted to a nursing facility, especially if the patient is on public aid. Long-term care Patients who are unable to live at home, for a variety of reasons, may go to a specialized long-term care facility with a TBI in-patient residential program. These patients usually need 24-hour supervision and have significant memory, judgment, and behavioral problems that make it impossible for family members to care for them. In most cases a long-term care facility is the last resort after unsuccessful home trial visits. The patient’s safety and the safety of the family is a main consideration in making this decision. TBI education for all involved: critical for optimal outcomes In the initial stages, education of the family is the first step to helping them understand and deal with their loved one’s injury. The family will ask for explanations from several parties – the physicians, nursing staff, social workers, etc. Redundancy is good in this situation because absorption of information is difficult for people who are living through a traumatic situation. Case managers need to be sensitive to ‘‘information overload’’ during this trying time and provide the family with just enough information.
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Education of the insurance provider is also important. It is imperative for the case manager to provide the insurance company with an understanding of the complexity of the injury, the time frames for recovery of the multiple injuries, the necessary rehabilitation, and the continuum of care. The case manager needs to lay out all the possible types of programs, services, equipment and personnel needs so the insurance company provides appropriate financial reserves for the care of the patient. An experienced case manager with thorough knowledge of TBI acts as a resource for the insurance company and an advocate for the patient. The case manager discusses the myriad of problems associated with TBI and the critical services needed to facilitate the patient’s recovery with the insurance company. Case managers have a variety of resources available to help them increase their knowledge of TBI. Books, articles, conferences, on-line resources, attending brain injury support group meetings, the Brain Injury Association of America and state brain injury associations are all helpful resources. There is also a voluntary national certification program for experienced professionals in brain injury services is offered by The American Academy for the Certification of Brain Injury Specialists (AACBIS) [7]. Rehabilitation services to the underinsured In most cases the hospital discharge planner will know of local facilities and funding requirements. Patients with no insurance attend programs funded by public aid. Each state has its own services available to patients with TBI. An excellent resource is the state brain injury association, which provides information on available services for rehabilitation. Some states also have vocational rehabilitation programs. There are also local TBI support groups are associated with each state brain injury association. TBI survivors, their family and friends, and other professionals are invited to attend. These groups are a community resource for networking, education, and support. Geographic disparities in resources and quality of services Major metropolitan areas typically have a wide range of services needed for a person with TBI and associated injuries. University medical centers outside of large cities would also have sufficient services. Rural areas, however, may not have trauma services and neurosurgeons [8]. The services available to patients with TBI vary widely from state to state. The Brain Injury Association of America’s National Directory of Brain Injury Rehabilitation Services lists all services available by state [9]. Planning therapy with limited financial reimbursement resources An example is a patient who had eight visits of outpatient rehabilitation therapy available from her insurance policy but was not ready for the physical level necessary for her to be able to participate and benefit from the
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services. It was suggested that she have home care services (included in her insurance plan) when she was discharged from the hospital. She had those services for 3 months and called at the end of that time to say she was ready to come to the outpatient program. An initial evaluation was completed in one session, and they were able to prioritize her deficit areas still needing compensatory strategies and work during the remaining sessions teaching those strategies. The patient also wanted to return to work and we referred her to the state vocational rehabilitation agency which was able to provide assistance in that area. Maneuvering through the uneven TBI rehabilitation play field Sometimes patients without private medical insurance may receive public aid and TBI Medicaid Waiver services [10]. These services are jurisdictionalspecific and vary by state. In some cases the patient can attend a brain injury support group sponsored by the state brain injury association or a local hospital/rehabilitation facility. These groups are attended by survivors as well as family and friends of the survivor, usually facilitated by a professional in the field of brain injury. As problems are discussed, participants put forth strategies to help the patients and their family members, that can help improve the injured person’s functional status. Many case managers work as facilitators of these groups and act as a resource for state and community services which the injured person is eligible to obtain. Obtaining extension of services Case managers may deal with challenges and complexities obtaining extended services for a patient. It is important to keep an open dialog and interaction with the insurance company to overcome these challenges. Shortening of a treatment plan Most TBI cases are complex and require multiple services. When there are multiple treating providers, the physiatrist/neurologist is generally the main treating physician. The main treating physician makes the referrals to the other providers. The main treating physician determines when the patient has hit a plateau in the recover process and also decides when treatment starts and when it stops. The case manager stays in close contact with the treating physician and objectively deals with conflicts which may arise between the other treating providers who may want certain treatments to continue. The case manager needs to remain objective and consistent in dealing with these conflicts. Advocating long-term care In some cases long-term care may be necessary for a patient. The funding available to the patient will determine where the patient goes for care.
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Patients funded by public aid will go to a nursing home which accepts public aid if the family is unable to care for him or her. If the patient’s family is able to care for him or her at home but needs assistance to make that happen, they can apply for state assistance. Again, services provided to patients with TBI vary greatly from state to state. For example, the state of Illinois has a Medicaid Waiver that funds support services for persons with TBI who reside at home with the goal of keeping these individuals at home as opposed to having to live in a nursing home [11]. Patients whose injuries resulted in a work related accident and who are funded by workers’ compensation insurance, can reside in a specialized long-term care facility for persons with TBI. Dealing with the legal system Case managers work with plaintiffs and defense attorneys. When working with an uncooperative patient, the case manager can usually work with the patient’s attorney and utilize the attorney as a resource. For example, if the case manager has a patient who misses medical appointments, he or she can contact the attorney and have the attorney contact the client to get him or her to attend the appointments. Challenges arise when the case manager deals with both an uncooperative patient and attorney. In this situation, the case manager can utilize the defense attorney for assistance. For example, he or she can request that the defense attorney contact the plaintiff’s attorney to help the file move to resolution. Attorneys will frequently investigate for the presence of pre-existing conditions. It is important for the case manager to examine the patient’s life pre-morbidly and compare it to the current level of function, see the deficits and set goals for remediation. If malingering is suspected through inconsistent behaviors, the case manager will suggest that a neuropsychologist conduct further testing.
Summary The case manager has the most comprehensive picture of the care continuum because he or she has contact with all the parties involved - the patient, family, physicians, therapists, insurance company, attorney, employer and community groups. It is absolutely necessary for the case manager to be knowledgeable about TBI and to keep all parties involved and up to speed on the patient’s needs and recovery. The case manager is an advocate for the patient and must be aware of all the available resources - financial, insurance, family support, and community resources, support groups, etc. The best in class case manager customizes a program for each patient which utilizes all available resources to facilitate optimal outcomes.
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Acknowledgment To my TBI patients and their families, for teaching me the complexities of brain injury and for learning that brain injury recovery truly is over a lifetime. References [1] Case management practice. CCMC Commission for Case Manager Certification. 2006. Available at: http://www.ccmcertification.org/pages/13frame_set.html. Accessed May 7, 2006. [2] Ashley MJ, Lehr RP, Krych DK, et al. Post-acute rehabilitation outcome: relationship to case-management techniques and strategy. J Insur Med 1994;26(3):348–54. [3] Teasdale G, Jennett B. Assessment of coma and impaired consciousness. Lancet 1974;2: 81–4. [4] Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochirurgica (Wien) 1976;34:45–55. [5] Mackay LE, Chapman PE, Morgan AS. Maximizing brain injury recovery: integrating critical care and early rehabilitation. Gaithersburg (MD): Aspen; 1997. p. 530–1. [6] Hagen C. The Rancho levels of cognitive functioning: a clinical case management tool, the revised levelsd3rd edition. Downey, California: Rancho Los Amigos Hospital; 1998. [7] American Academy for the Certification of Brain Injury Specialists. 2006. Available at: http://www.aacbis.net. Accessed June 1, 2006. [8] Copp J. A profession at risk. American Association of Neurological Surgeons Bulletin 2001; 10(3):6–14. [9] Brain Injury Association of America. Available at: http://www.biausa.org/. Accessed June 1, 2006. [10] Medicaid waivers and demonstrations list. 2006. US Department of Health & Human Services. Centers for Medicare and Medicaid Services. Available at: http://www.hhs.gov. Accessed June 1, 2006. [11] HCBS Waiver for Persons with Brain Injury. 2005. Illinois Department of Healthcare and Family Services. Available at: http://www.hfs.illinois.gov. Accessed June 5, 2006.
Traumatic Brain Injury Rehabilitation: Case Management and Insurance-Related Issues Helaine Tobey Pressman, MS, CCC/SLP-L, CBIT, CCM* Intracorp, 525 W. Monroe Street, Chicago, IL 60661, USA
Traumatic Brain Injury (TBI) cases are medically complex, involving the physical, cognitive, behavioral, social, and emotional aspects of the survivor. Often catastrophic, these cases require substantial financial resources not only for the patient’s survival but to achieve optimal outcomes for a functional life, including the return to family and work responsibilities for the long term. TBI cases involve the injured person, the family, medical professionals, treating physicians, therapists, attorneys, the employer, community resources and in most cases an insurance company. Case managers help to facilitate a successful return to family and work by collaborating with all parties, assessing priorities and options, coordinating services, and educating and communicating with all concerned. The case manager acts as health care and human services professional. He or she adheres to standards of privacy and confidentiality and handles all medical and jurisidictional issues in an ethical manner [1]. Ashley and colleagues [2] have discussed the positive relationship between effective case management and a productive clinical therapy program in a successful outcome for the patient who has TBI. A key component in achieving successful outcomes as a case manager of brain injury cases is to have a thorough knowledge of TBI. When managing TBI cases, it is important to discern not only the major deficits but also the subtleties of minor deficits that may not be apparent to the involved parties. These major deficits can impact the survivor’s future acquisition of lost skills and his or her success in achieving the necessary outcomes to be able to return to a healthy, functional, and productive life. * 390 Greenwood Avenue, Glencoe, IL 60022. E-mail address: [email protected] 1047-9651/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.pmr.2006.11.006 pmr.theclinics.com
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Insurance Case managers have learned how to navigate the ever changing managed care system. In the last twenty years medical costs have increased and treatments have changed. Insurance coverage and benefits also vary significantly from person to person because there are a multitude of companies and policies. In some cases a claimant may have a lifetime coverage limit. But it can be exhausted with one catastrophic injury costing over 1 million dollars. Some insurance policies have benefits for therapy (physical, occupational, and speech), home care, durable medical equipment, and attendant care, others do not. In an ideal situation where there are sufficient resources, the case manager works with the patient (survivor), family, physicians, therapists, attorneys, insurance company, and employer.
TBI case management issues When reviewing records for the initial evaluation in the hospital phase, it is necessary to review the emergency medical technician’s records at the site of injury. This review helps you understand the mechanism of injury [3,4] at the scene of the accident and loss of consciousness information. The patient typically does not remember the accident and may be in a stage of posttraumatic amnesia after the event. These types of responses are typically unreliable at this stage. The length of time the patient spends in this stage varies. The patient will probably not remember the hospitalization, but the family certainly will. Family involvement plays a key role in the patient’s recovery. Studies show that patients with strong family support fare better than their counterparts without support and family involvement positively affect outcomes [5]. During recovery, the patient’s perception of his or her abilities and deficits can vary greatly from the perceptions of others. Anosognosia, a lack of awareness, is common in persons with TBI. Questioning the family as to the actual abilities of the patient is important because the actual levels of ability are perceived differently by the patient and the family. It is important to share this information with the physician(s). A person with TBI often has several other injuries, making the case complex. There are often neurosurgical, neurologic, cognitive, communicative, orthopedic, visual, hearing, balance, and psychologic areas affected. With the multiple treating physicians and therapists, it is critical for the case manager to communicate information among this varied group. At first, the neurosurgeon may direct initial rehabilitation in the ICU and acute care phase. As the patient’s neurosurgical status stabilizes, care should be transitioned to the direction of the specialist in physical medicine and rehabilitation who has a strong background in TBI. Physicians generally have a short time to spend with the patient at each visit and may not be able to observe
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the patient in a prolonged, real life environment. It is important for the family to provide the physician with a true picture of the patient’s abilities and deficits. It is also very important for the case manager to communicate clinical information among all treating providers since there can be several. Additionally, coordination of care is critical. The patient may need surgery for one condition which may need to supersede treatment of another problem. The case manager coordinates communication between providers, thereby helping to optimize recovery of the patient. The role of the case manager in the continuum of care The case manager can receive a case at any phase in this continuum of care and recovery. Depending on the stage at which the case is received, different work may be needed. In some cases, when a case is received at a later stage in the continuum, the case manager may work with the physicians to determine if all necessary care and treatment were given to the patient. If it is determined that additional care was needed in an earlier stage, the injured person may need to go back for further care. This continuum of care is a general guide and the case manager will work to explain the guide to the insurance company to ensure that reserves are adjusted, if necessary, during the rehabilitation course. Hospital (ER, ICU, acute care) The initial referral to the case manager will include instructions to obtain the medical records, cause of injury, surgical information, and plan of care from the treating physician. Generally, the first task is to meet with the Utilization Review personnel at the hospital to obtain permission and information and to meet with the patient and family. In catastrophic cases, a trauma care coordinator acts as the hospital liaison with the case manager. The case manager explains his or her role in facilitating any necessary communication between the hospital and the insurance company. The case manager’s involvement is a mutually beneficial and cooperative because both parties need the assistance of the other in management of the case. The case manager meets with the patient to determine his or her status and to put the medical records into context. A visual meeting can tell him or her a lot about the status of the patient and puts the medical records into context when they are reviewed. The case manager also meets with the family to see how they are coping with the injury and explains his or her role in assisting with the care of their family member to evaluate the services needed and the options available to meet the injured person’s recovery needs. The case manager aims to build a rapport with the family and to elicit cooperation by explaining that he or she will be working with the family through the continuum of the recovery for the long-term. In cases where the claimant has suffered a work related injury, the case manager explains that the long-term goal is to facilitate their loved one to the point of recovery where he or she
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will be able to return to work. During this time in the care continuum it is important to remember that the family has just been through a traumatic event and emotions are running high. Attempt to keep the family focused on the positive and give them an end recovery goal to work toward. In most cases, when the patient emerges from coma, is able to respond to localized external stimuli (Rancho level 3) [6], and is medically stable, he or she is transferred to acute hospital care for a short period of time and then to inpatient rehabilitation. At the acute hospital phase, the case manager will encourage and assist the family in visiting the in-patient rehabilitation unit (units which specialize in treatment for TBI). The case manager helps prepare the family in advance so that they know what to expect when visiting the patient. As a person with TBI starts to ‘‘wake up,’’ he or she can become agitated and may become physically and verbally aggressive. This stage is referred to as Rancho Level 4-5 [6]. If the family is not prepared for this type of behavior it can be very disturbing. The case manager will explain that this behavior proves the patient is moving up the recovery scale and that the reason for agitation and aggressive behavior is due to the patient’s confusion and hypersensitivity to sound, light and touch. The Brain injury unit staff will manage these behaviors while keeping the patient safe by providing specialized treatment, controlled stimulation, a controlled environment and specialty equipment. The medical staff, along with the case manager, will educate the family about the brain injury and explain the patient’s needs so that when the family visits they will have an understanding of what the TBI unit provides. The case manager will help to put this information into context for the family and discuss future steps in the care continuum process. The case manager also updates the insurance company on the stages of progress across the care continuum. The case manager explains progress and the steps necessary for the patient to achieve a functional and productive life to ensure adjustments are made to the patient’s reserves as necessary. The end goal is always to assist the patient in recovery so that he or she may return to a productive lifestyle and in workers’ compensation cases in particular, to return the patient to the same job with the same employer. Sub-acute facilities Sub-acute facilities may exist as a unit in an acute care or rehabilitation hospital or in a nursing home. Patients are admitted to this type of facility if they are unable to sustain at least 3 hours of therapy per day. As their medical status improves, they are transferred to an inpatient rehabilitation hospital. The case manager will obtain updated information at least once a week at this level of care or more frequently depending on the patient’s medical status. Rehabilitation hospital (inpatient) At this level in the continuum of care, the injured person is physically able to participate in at least 3 hours of therapydphysical, occupational, and
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speech/cognitive/communicative/dysphagia (swallowing) therapy. A neuropsychologic evaluation is performed when the patient has sustained attention and concentration and can participate in a meaningful manner. If the patient is physically unable to participate for 3 hours a day, then he or she will be admitted to a subacute rehabilitation facility where the therapy demands are less. As the patient becomes stronger and more responsive, he or she can transfer to an inpatient rehabilitation unit. The case manager attends patient care conferences, usually on a weekly basis, with the rehabilitation team, obtaining medical and rehabilitation status and a time frame for discharge. The discharge location is important because the rehabilitation team needs to set goals with the patient (as possible) and his or her family. If the patient is to be discharged home, the family will need to be closely involved in the rehabilitation, participate in family teaching by the different therapists, and be able to understand the need for 24-hour supervision if necessary. Financial resources play an important role in determining the discharge site. The discharge planner in the hospital will assist the family in obtaining state and federal medical assistance if necessary. The discharge site may change again depending on the finances available. Home health care When the patient is able to be discharged to home, or in some cases, refuses to go to an inpatient facility and insists on returning home, home health services are often a good alternative. Home health services are often covered in medical insurance policies and many have specialized traumatic brain injury programs with therapists who can treat the injured person at home. A home based program can be an advantage in that the injured person is in a familiar setting and the rehabiliation is done in a functional, real-life environment. The case manager communicates separately with all therapists and the home health nurse because there is no team structure in a home based program. However, in a specialized program, the case manager coordinates team conferences where all team members are in communication with each other. Community re-entry program (residential and outpatient day program) Community re-entry programs are staffed by trans-disciplinary TBI rehabilitation teams which address the deficits in individual and group environments at home and in the community. The case manager attends regularly scheduled team conferences, usually on a monthly basis, with the rehabilitation team, including the injured person and his or her family members. Rehabilitation usually lasts for several months; vocational rehabilitation, if appropriate, is integrated into the program as early as possible. The case manager facilitates communication between the vocational specialist and the employer, incorporating the patient’s job description into the total rehabilitation program. During the community re-entry level of rehabilitation,
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the patient may feel frustration in dealing with the challenging rehabilitation. The case manager works with the patient to increase the complexity and duration of the rehabilitation as time goes on in order to approach the level of function the patient was able to perform pre-morbidly. During this time, the case manager attends all follow-up physicians’ appointments and communicates the patient’s rehabilitation status to the medical professionals and to the insurance company. TBI patients may also see a neurodevelopmental or behavioral optometrist to correct visual-perceptual and balance deficits through the use of specialized prism lenses and exercises. An evaluation by a neurodevelopmental and/or behavioral optometrist helps direct the physical and occupational therapists to assist the patient in performing specific and detailed exercises resulting in more functional outcomes than typical therapy alone. Prescription lenses also help to eliminate the visual-perceptual deficits without physical or occupational therapy intervention at all, depending on the individual patient. Skilled nursing facility In some cases, even after acute rehabilitation is complete, the patient may remain at a low functional level and not be able to return home. In this scenario the patient is admitted to a skilled nursing facility for long-term care. Lack of medical insurance for a specialized TBI rehabilitation facility can also cause the patient to be admitted to a nursing facility, especially if the patient is on public aid. Long-term care Patients who are unable to live at home, for a variety of reasons, may go to a specialized long-term care facility with a TBI in-patient residential program. These patients usually need 24-hour supervision and have significant memory, judgment, and behavioral problems that make it impossible for family members to care for them. In most cases a long-term care facility is the last resort after unsuccessful home trial visits. The patient’s safety and the safety of the family is a main consideration in making this decision. TBI education for all involved: critical for optimal outcomes In the initial stages, education of the family is the first step to helping them understand and deal with their loved one’s injury. The family will ask for explanations from several parties – the physicians, nursing staff, social workers, etc. Redundancy is good in this situation because absorption of information is difficult for people who are living through a traumatic situation. Case managers need to be sensitive to ‘‘information overload’’ during this trying time and provide the family with just enough information.
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Education of the insurance provider is also important. It is imperative for the case manager to provide the insurance company with an understanding of the complexity of the injury, the time frames for recovery of the multiple injuries, the necessary rehabilitation, and the continuum of care. The case manager needs to lay out all the possible types of programs, services, equipment and personnel needs so the insurance company provides appropriate financial reserves for the care of the patient. An experienced case manager with thorough knowledge of TBI acts as a resource for the insurance company and an advocate for the patient. The case manager discusses the myriad of problems associated with TBI and the critical services needed to facilitate the patient’s recovery with the insurance company. Case managers have a variety of resources available to help them increase their knowledge of TBI. Books, articles, conferences, on-line resources, attending brain injury support group meetings, the Brain Injury Association of America and state brain injury associations are all helpful resources. There is also a voluntary national certification program for experienced professionals in brain injury services is offered by The American Academy for the Certification of Brain Injury Specialists (AACBIS) [7]. Rehabilitation services to the underinsured In most cases the hospital discharge planner will know of local facilities and funding requirements. Patients with no insurance attend programs funded by public aid. Each state has its own services available to patients with TBI. An excellent resource is the state brain injury association, which provides information on available services for rehabilitation. Some states also have vocational rehabilitation programs. There are also local TBI support groups are associated with each state brain injury association. TBI survivors, their family and friends, and other professionals are invited to attend. These groups are a community resource for networking, education, and support. Geographic disparities in resources and quality of services Major metropolitan areas typically have a wide range of services needed for a person with TBI and associated injuries. University medical centers outside of large cities would also have sufficient services. Rural areas, however, may not have trauma services and neurosurgeons [8]. The services available to patients with TBI vary widely from state to state. The Brain Injury Association of America’s National Directory of Brain Injury Rehabilitation Services lists all services available by state [9]. Planning therapy with limited financial reimbursement resources An example is a patient who had eight visits of outpatient rehabilitation therapy available from her insurance policy but was not ready for the physical level necessary for her to be able to participate and benefit from the
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services. It was suggested that she have home care services (included in her insurance plan) when she was discharged from the hospital. She had those services for 3 months and called at the end of that time to say she was ready to come to the outpatient program. An initial evaluation was completed in one session, and they were able to prioritize her deficit areas still needing compensatory strategies and work during the remaining sessions teaching those strategies. The patient also wanted to return to work and we referred her to the state vocational rehabilitation agency which was able to provide assistance in that area. Maneuvering through the uneven TBI rehabilitation play field Sometimes patients without private medical insurance may receive public aid and TBI Medicaid Waiver services [10]. These services are jurisdictionalspecific and vary by state. In some cases the patient can attend a brain injury support group sponsored by the state brain injury association or a local hospital/rehabilitation facility. These groups are attended by survivors as well as family and friends of the survivor, usually facilitated by a professional in the field of brain injury. As problems are discussed, participants put forth strategies to help the patients and their family members, that can help improve the injured person’s functional status. Many case managers work as facilitators of these groups and act as a resource for state and community services which the injured person is eligible to obtain. Obtaining extension of services Case managers may deal with challenges and complexities obtaining extended services for a patient. It is important to keep an open dialog and interaction with the insurance company to overcome these challenges. Shortening of a treatment plan Most TBI cases are complex and require multiple services. When there are multiple treating providers, the physiatrist/neurologist is generally the main treating physician. The main treating physician makes the referrals to the other providers. The main treating physician determines when the patient has hit a plateau in the recover process and also decides when treatment starts and when it stops. The case manager stays in close contact with the treating physician and objectively deals with conflicts which may arise between the other treating providers who may want certain treatments to continue. The case manager needs to remain objective and consistent in dealing with these conflicts. Advocating long-term care In some cases long-term care may be necessary for a patient. The funding available to the patient will determine where the patient goes for care.
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Patients funded by public aid will go to a nursing home which accepts public aid if the family is unable to care for him or her. If the patient’s family is able to care for him or her at home but needs assistance to make that happen, they can apply for state assistance. Again, services provided to patients with TBI vary greatly from state to state. For example, the state of Illinois has a Medicaid Waiver that funds support services for persons with TBI who reside at home with the goal of keeping these individuals at home as opposed to having to live in a nursing home [11]. Patients whose injuries resulted in a work related accident and who are funded by workers’ compensation insurance, can reside in a specialized long-term care facility for persons with TBI. Dealing with the legal system Case managers work with plaintiffs and defense attorneys. When working with an uncooperative patient, the case manager can usually work with the patient’s attorney and utilize the attorney as a resource. For example, if the case manager has a patient who misses medical appointments, he or she can contact the attorney and have the attorney contact the client to get him or her to attend the appointments. Challenges arise when the case manager deals with both an uncooperative patient and attorney. In this situation, the case manager can utilize the defense attorney for assistance. For example, he or she can request that the defense attorney contact the plaintiff’s attorney to help the file move to resolution. Attorneys will frequently investigate for the presence of pre-existing conditions. It is important for the case manager to examine the patient’s life pre-morbidly and compare it to the current level of function, see the deficits and set goals for remediation. If malingering is suspected through inconsistent behaviors, the case manager will suggest that a neuropsychologist conduct further testing.
Summary The case manager has the most comprehensive picture of the care continuum because he or she has contact with all the parties involved - the patient, family, physicians, therapists, insurance company, attorney, employer and community groups. It is absolutely necessary for the case manager to be knowledgeable about TBI and to keep all parties involved and up to speed on the patient’s needs and recovery. The case manager is an advocate for the patient and must be aware of all the available resources - financial, insurance, family support, and community resources, support groups, etc. The best in class case manager customizes a program for each patient which utilizes all available resources to facilitate optimal outcomes.
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Acknowledgment To my TBI patients and their families, for teaching me the complexities of brain injury and for learning that brain injury recovery truly is over a lifetime. References [1] Case management practice. CCMC Commission for Case Manager Certification. 2006. Available at: http://www.ccmcertification.org/pages/13frame_set.html. Accessed May 7, 2006. [2] Ashley MJ, Lehr RP, Krych DK, et al. Post-acute rehabilitation outcome: relationship to case-management techniques and strategy. J Insur Med 1994;26(3):348–54. [3] Teasdale G, Jennett B. Assessment of coma and impaired consciousness. Lancet 1974;2: 81–4. [4] Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochirurgica (Wien) 1976;34:45–55. [5] Mackay LE, Chapman PE, Morgan AS. Maximizing brain injury recovery: integrating critical care and early rehabilitation. Gaithersburg (MD): Aspen; 1997. p. 530–1. [6] Hagen C. The Rancho levels of cognitive functioning: a clinical case management tool, the revised levelsd3rd edition. Downey, California: Rancho Los Amigos Hospital; 1998. [7] American Academy for the Certification of Brain Injury Specialists. 2006. Available at: http://www.aacbis.net. Accessed June 1, 2006. [8] Copp J. A profession at risk. American Association of Neurological Surgeons Bulletin 2001; 10(3):6–14. [9] Brain Injury Association of America. Available at: http://www.biausa.org/. Accessed June 1, 2006. [10] Medicaid waivers and demonstrations list. 2006. US Department of Health & Human Services. Centers for Medicare and Medicaid Services. Available at: http://www.hhs.gov. Accessed June 1, 2006. [11] HCBS Waiver for Persons with Brain Injury. 2005. Illinois Department of Healthcare and Family Services. Available at: http://www.hfs.illinois.gov. Accessed June 5, 2006.