This article was recently published in The Wharton Healthcare Management Alumni Association newsletter.
The term “outcome” assumes some sort of final conclusion. Outcomes from a clinical perspective, typically presumes finality (for example, the outcome of an appendectomy is the removal of the diseased appendix). Unfortunately, when it comes to the process of recovering from a traumatic brain injury, nothing could be farther from the reality of the situation.
The outcome for a person who has sustained a TBI is a moving target. Discharge status has become confused with outcome. Or, said a different way, the assumption is often made that discharge from a rehabilitation unit is the final outcome and now everyone can get on with their lives. Families quickly learn that being home can present enormous challenges that are often beyond their capability to manage. This is especially true in situations where behavioral issues come into play.
We frequently receive referrals of individuals who have been discharged home but either immediately, or over time, begin decompensate from a behavioral standpoint. Verbal and physical aggression, agitation, irritability and impulsivity often emerge and make reestablishing family and community connections very challenging. Initial effort in working toward a sustainable outcome for these individuals, which also includes the goal of successful community re-engagement, starts with a comprehensive evaluation. Questions which need to be answered include:
- Are the behaviors are a function of skill deficits and resultant frustration?
- What does the individual gain or expect to gain from the behavior?
- Does the individual have some degree of control and awareness of the consequences of the behavior?
Once these questions are answered, interventions can begin and be integrated into a plan that defines where the person is headed and who will support them in pursuit of their goals at home and in the community.
A central component to sustainable outcomes is a well-established and meaningful daily activity pattern with supporting strategies for the family and those who are connected with the individual. This may include ways to be in the community but minimize exposure to provocative environments (noisy, busy over stimulating situations) as well as helping families recognize when someone needs a break or how to schedule time for a series of activities without overtaxing the individual. These efforts represent an opportunity to act positively and help maintain one’s social connections which are key elements to long term success. Ultimately, family, social pursuits, social networks and being a part of the community of one’s choosing is the outcome we all strive for. Professionals must recognize that for individuals who have sustained a TBI directing the process of re-engagement and utilizing the community for rehabilitation is a critical piece to a meaningful outcome.
Dave Krych serves as Vice President of Market Development for ReMed and has spent his professional career serving people with traumatic brain injuries. While at Southern Illinois University, where he earned his graduate degree in Speech/Language pathology , he was part of the country’s first post acute community based program for survivors of traumatic brain injury. Putting what he’d learned to work, he co founded a post acute brain injury facility, opening programs in California and Texas. Dave joined ReMed in 2005.
During Brain Injury Awareness Month Let’s Remember the Families
Families often tell a story of how a tragic accident changed their lives forever. Their journey is painful, unexpected, and life-altering. While they endorse laughter, gratitude and kindness of friends, family members and caregivers, sometimes hostility, bossiness and resistance can take over.
Ann Marie McLaughlin PhD, a ReMed Psychologist and Clinical Director points out staff who work with brain injured patients and their relatives are charged with the seemingly paradoxical task of helping families support our rehabilitation efforts and be goal oriented, while simultaneously communicating often negative realities about prognosis. Stern et al summarizes complex interactions toward the team by family members can include expressions of hostility, aggression, and more critical opinions ranging from concerns to frank accusations. Gans a rehabilitation psychologist (1993) encourages the health care professional to see the hate as an expression of powerlessness. The family who served in the past as nurturer now must relinquish this role to the team.
While there is no optimal way to deal with the distressed family, general approaches are useful. Staff will deal better with the family negativity if they remember:
- it is usually coming from the clinical constellation of brain injury symptoms which are confusing and frightening – not from a deliberate intent to act unreasonably.
- while providing education and support, keep in mind the family may not be able or ready to hear the information.
Staff should have a keen awareness of the effects of their limit setting. (For example, limiting visiting hours without rationale can seem provocative and insensitive to the family.) The family’s interests and needs are an essential part of a treatment. Even over the long term, the family wants the team to know who their loved one was before their injury and the family wants to be a respected member of the team.
At a conference many years ago, Marilyn Spivak, founder of the National Head Injury Foundation (now the BIAA), advocate and parent reminded us that sometimes we come across with extreme pessimism and that should be replaced with realism. In the end, the family and the team have the same goal: the best outcome for client.
Mary Pat Murphy, ReMed’s Vice President of Clinical Services is serious about ReMed providing exceptional rehabilitation, but beyond that, she wants ReMed’s staff be seen as leaders in the niche areas of brain injury – behavior, community integration and co-occurring disorders. Her commitment to ReMed is to ensure that what we do is “evidence based”. Through her professional affiliations with the Association of Rehabilitation Nurses (ARN) and American Congress of Rehabilitation Medicine (ACRM), she provides a clinical perspective that ensures ReMed continues to be a leader in the field.
Concussion, starring Will Smith, was a major step forward in the arena of traumatic brain injury. So many of us have been working diligently for decades to provide important, high quality services and care to this group of individuals in need, yet never before has the topic been thrust into the mainstream media in this fashion. Of course, the field extends far beyond concussive-type injuries that are the subject of the movie, in the context of safety issues for NFL players. Nonetheless, the movie serves to create widespread awareness of these types of injuries and the long-term impact they can have on the human brain, not to mention the scope and severity of symptoms that result, especially in the absence of proper rehabilitation and care. The movie does a fantastic job of providing a simple description for the lay-person of how such injuries can be caused to the brain which is floating within a fluid-filled sack inside the skull.
In addition to the clinical subject matter, various elements of the story really hit home for us here at ReMed, given that the events of the movie transpire in Pittsburgh, a market we have served directly for over 20 years and one in which we know the relevant providers and the dynamics of the local health care systems. There has been an evolution in the clinical community regarding the understanding of brain injuries and how best to provide rehabilitative services for those who must live with them. No doubt, this movie is creating a heightened level of awareness among the general population, and momentum will grow in terms of this broader understanding. Hopefully, more individuals with symptoms of brain injury will recognize their symptoms and seek appropriate care AND insurance companies will provide necessary payment for treatment, recognizing that a proactive approach reduces costs over the long-term, versus delaying needed care and having to manage negative consequences.
Of course, ReMed is based in the suburbs of Philadelphia, so we are quite proud that local product Will Smith delivered such a superior and convincing performance in the role of Dr. Bennet Omalu. Let’s hope he receives recognition for his impressive character portrayal, so that more momentum will build and more attention will be paid, as relates to the public’s understanding that a concussion, while considered a mild brain injury, can produce complex issues that can have serious long-term effects. Concussion is something that must be taken– and treated – seriously.
Jamie Richter serves as the Vice President of Business Development at ReMed, applying his 25 years of diverse experience within the health care industry to various growth initiatives throughout the company. He has a proven track record of achieving results and focusing on driving growth so that more individuals in need can gain access to high quality services.
A strong leadership team is important to the success of any organization as a critical part of creating agreement around mission, values and vision. At ReMed, company culture has been developed, rather than forced, over 30+ years. This creates staff (often referred to as ReMedians, a term coined by our first Medical Director many years ago) that understand the importance of their role within the larger framework of the organization. Good leadership can be felt throughout an entire organization. Conversely, poor leadership leads to high turnover, lower morale and the inability to sustain a successful organization over time.
ReMed is led by a dynamic and well-seasoned senior management team, which has an average of over 20 years of industry related experience. In addition to a talented and diverse management team, ReMed has many seasoned staff at all levels of the organization. Seasoned staff serve as leaders everyday, mentoring and modeling for newer ReMedians. 32 years after being founded in 1984, ReMed is proud of our statistic of 5 staff who have been with the company for more than 25 years and 20 staff who have been with ReMed 20 years.
It is important for anyone taking a leadership role to remember, it is not a title that makes you a leader but a label you earn from the people you lead. Warren Bennis, widely regarded during his lifetime as a pioneer in the field of contemporary leadership studies said, “A business short on capital can borrow money and one with poor location can move but a business short on leadership has little chance of survival”.
Elaine Lecatsas, serves as the Vice President of Operations for ReMed implementing the overall direction and philosophy for company operations, as well as overseeing risk management and legal issues, Human Resources, Facilities Management, Accreditation and Licensing and management of ReMed’s administrative functions. Under Elaine’s leadership, ReMed was honored by the American Psychological Association is 2012 as a Psychologically Healthy Workplace National Award Winner as well as a Best Practices Honoree. She is a dynamic and detail oriented professional who strives for equality and consistency throughout the organization.
Our mission says we provide exceptional and innovative supported living services … and I have learned, this year, that a peaceful ending is a critical element to lives that we have supported for many years.
These are hard good byes. They are hard for me because I’ve watched these people come to ReMed, often as a last ditch effort, and slowly and steadily rebuild a life that has meaning and is worth living every day. They are hard for me because I see our staff, who do their jobs well every day and in the process, can’t help but become second families to them. And I see their families who are now grieving a second loss of their loved one.
Over the past week and what I have known for years is we provide so much more. We have group of people that have heart and soul and allow the people we serve to live on their own terms. Part of that is learning to handle life, death and the sadness of losing someone we have known for so long.