Outpatient Rehabilitation

Outpatient care is often the least organized branch of ABI care. Patients discharged home often receive no therapy or minimal support depending on their level of need and payment status. In a well-structured outpatient facility in Canada, patients typically attend therapy two to three times per week and have access to an occupational therapist, physiotherapist, speech language pathologist, social worker, physiatrist, neuropsychologist and neuropsychiatrist (Cullen 2007). At some facilities, for example in Hamilton, Ontario, patients also receive the services of a rehabilitation counselor which has been reported to be effective. Despite the effectiveness, access to programs like these often depends on funding. Patients with private insurance from motor vehicle accidents are 1.6 times more likely to be discharged home with supportive services than those without (Kim et al. 2006). Drag et al. (2013) reported that US TBI-veterans were significantly more likely to utilize outpatient services and were almost nine times more likely to be hospitalized than non-TBI veterans. The authors argue that earlier intervention and increased monitoring may be needed to reduce the burden on outpatient healthcare (Drag et al. 2013). In a study by Leith et al. (2004), focus groups of patients and families were questioned regarding their perceived post-discharge needs. The five areas of need included: early, continuous, comprehensive service delivery; information and education; formal and informal advocacy; empowerment of persons with TBI and their families; and human connectedness and social belonging (Leith et al. 2004). Subsequently, a survey conducted in the US to identify the availability of community information resources post ABI (Sample & Langlois 2005). Three recommendations for improvement were made: expand the population targeted for linkage to services, improve access to information about available services, and increase the availability of services (Sample & Langlois 2005).

Residential care facilities are generally not-for-profit, government sponsored agencies that offer access to support in a secure environment with staff specifically trained in ABI care. Resources often include rehabilitation therapists, behavior therapists, social workers and case managers, with supervision by certified psychologists (Powell et al. 2002). These facilities aim to allow patients with ABI an extended system of support, with opportunities for long-term rehabilitation. However, they are generally expensive and access is often limited by the patient’s ability to pay for care. Alternatives include hospital based outpatient facilities where patients drop in several times a week for care (Cullen 2007) or mobile rehabilitation teams which visit the patient in their home (Ponsford et al. 2006). Programs targeting specific goals including social interaction (Cope et al. 2005), driving (Rapport et al. 2008) and competitive employment (Willer et al. 1999) also exist. They generally take place on a one-to-one basis in home or in the community and patients often rate these final steps as the most important in returning to normalcy (Evans 1997).

Individual Studies 

Table: Well Being Post Rehabilitation

Discussion

In terms of outpatient care there are several similarities to inpatient rehabilitation. A multidisciplinary approach is still favourable for outpatient services, and timely rehabilitation is imperative as patients are often sent home too early and referred to outpatient services too late (Jeyaraj et al. 2013).  However, a longer duration of rehabilitation is suggested but with less intensity to allow patients to integrate back into daily life. Jeyaraj et al. (2013) note that there is a need to train clinicians who provide community services about how best to assist individuals with ABI and increase the amount of community resources. Cusick et al. (2003) compared individuals enrolled in a Medicaid Waiver Program to those receiving no outpatient Medicaid support. Although patients in the Medicaid waiver program showed higher levels of resource use, as well as improved mental health status and less substance abuse, the control groups scored better on independence based measures (i.e., physical, cognitive, and mobility). Given all the confounding variables that were not controlled for, firm conclusions cannot be drawn from this study; however, such programs seem promising in terms of helping patients with ABI access appropriate services. In terms of services, it is important to highlight the findings of Turner et al. (2009) that showed stress and depression significantly increased over time after rehabilitation. Although the focus is often on functional status, it is crucial that the psychological wellbeing of individuals with ABI is remembered during this transitional phase. 

Braunling-McMorrow et al. (2010) looked at the benefits of participation in a weekly program that included both behavioural and cognitive therapies that would teach participants to respond to various life events appropriately and allow for greater independence. Those in the neurobehavioural group admitted within the first six months of injury showed greater improvement than those admitted later. The study authors suggest that injury severity may have been a factor, with more severe cases being admitted sooner. As well, for those admitted later, gains had already been made and this may have made the gains in the program appear less significant (Braunling-McMorrow et al. 2010).

In terms of where outpatient services are provided, one study found that patients with TBI given rehabilitation in a residential treatment center made significantly greater gains in terms of motor and cognitive functioning than those receiving rehabilitation in a nursing facility or at home (Willer et al. 1999). The groups, however, did not differ at discharge or at a one year follow-up on a measure of community integration (Willer et al. 1999). Another study by Ponsford et al. (2006) compared outpatients treated in the community to those who returned to the hospital for outpatient care. The findings indicate that patients who received outpatient care were significantly less dependent on support from close others, more independent in mobility, displayed fewer inappropriate social behaviours and had less difficulty with motor speech and following conversations than those receiving community based-rehabilitation. No significant differences were shown in terms of employment outcomes. Similarly, Malec and Degiorgio (2002) reported that patients in three different rehabilitation pathways, who differed in terms of cognitive functioning and disability, were able to succeed in terms of community-based employment. The study highlights the need for an individualized approach to ensure successful integration into the community. The intensity of therapy and the resources and interventions offered must match the individual’s needs, severity of injury, and goals, among other factors (Malec & Degiorgio 2002). As noted by Ponsford et al. (2006) some community-based programs are lower in cost than hospital based services, and resources are often limited. Therefore, the benefits and limitations of all outpatient services need to be considered with the realities of the current healthcare system in mind.  

Conclusions

There is Level 2 evidence that behavioural and cognitive skills post ABI can be improved by participating in neurorehabilitation or neurobehavioural programs.

There is Level 2 evidence that multidisciplinary outpatient rehabilitation can improve functional outcomes up to one year post discharge.

 

 

The type and intensity of outpatient services offered to an individual should take into account the severity of injury, patient characteristics, and patient goals.

Multidisciplinary outpatient rehabilitation can improve functional outcomes up to one year post discharge.

Neurobehavioural or neurorehabilitative programs improve behavioural and cognitive functioning post ABI.

To provide optimal outpatient care there is a need to educate clinicians, in general healthcare settings, about the needs and management of patients with ABI.

Community resources for patients with ABI are limited and are influenced by the availability of funding.

A challenge in outpatient rehabilitation is ensuring patients receive timely rehabilitation. Many patients are referred to outpatient services too late or discharged home too early.