3.3 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 2-3 times /wk and have access to OT, PT, SLP, SW, physiatrist, neuropsychology and neuropsychiatry 54. At a similar facility in Hamilton, Ontario patients also receive the services of a rehabilitation counselor which has been reported to be effective.  However, access to programs like these often relies 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 50.  A survey conducted in the United States was conducted to identify the availability of community information resources post ABI in the US 83. The authors made three recommendations for improvement: expand the population targeted for linkage to services, improve access to information about available services, and increase the availability of services. In a similar study by Leith et al. 84, focus groups of patients and families were questioned regarding their perceived post-discharge needs in South Carolina, USA Consensus agreement surrounded five areas of need; 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.  

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, behaviour therapists, social workers and case managers with supervision by certified psychologists 54;85. These facilities aim to allow ABI patients 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 54or mobile rehabilitation teams which visit patients at home 86.

Other programs aim at aiding less severely injured patients in community reintegration and independence. These services involve specifically targeted goals including social interaction 12. driving 87and competitive employment 88. 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 57.

What evidence is there supporting patient participation in outpatient rehabilitation services post ABI?

  1. There is Level 3 evidence that multidisciplinary outpatient rehabilitation may improve functional outcomes up to ne year post discharge.
     
  2. There is Level 2 evidence that behavioral and cognitive skills post ABI can be improved by participating in neurorehabilitation or neurobehavioral programs.

Four non-randomized control trials were also located which assessed outpatient care. Ponsford et al. 86compared patients treated in the community post-discharge to patients who returned to hospital for care. They found that patients who received hospital 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. However, community patients showed increased physical independence. Cusick et al. 89matched patients receiving MEDICAID waiver community support to patients from a TBI database. They found very few differences within 4 outcome measurement scales. Patients in the waiver program showed higher levels of resource use as well as improved mental health status and less substance abuse. Patients not receiving waiver support showed increased levels of predominantly independence based measures (ie. physical, cognitive, and mobility independence). Similarly, Willer et al. 88compared patients receiving residential inpatient rehabilitation to a control group receiving in-home outpatient services. They found patients treated in a residential center improved in motor and cognitive function, but patients treated at home showed improvements in independence and social integration levels. All three studies identified differences in pressures placed on ABI patients. As would be expected, patients receiving care tend to improve in the skills targeted by that care while those receiving less structured care, or no care at all, improve in independence skills. Further study regarding appropriate target groups for differently structured programs is necessary.  

Braunling-McMorrow et al.90looked 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. Individuals who participated were placed in two groups: those requiring neurorehabiliation (NR) and those requiring neurobehavioural (NB) treatment. Results from theFAOM (functional area outcome menu) indicated that both groups improved significantly pre to post assessment (p<0.001). Scored on the FAOM at the one year post discharge time period, indicate that those in the NB showed the greatest change.  Individuals who were admitted to the program within the first 6 moths of injury did better than those admitted later. The study authors suggest that perhaps the severity of deficits may have played a role in the time of admission to rehabilitation with those with more severe deficits being admitted to rehabilitation sooner than those with fewer deficits. Those who entered rehabilitation at a later date may have already made improvements, thus those made in the program were not as significant 91.

We located one other study which focused on comparisons of outpatient rehabilitation services. Malec and Degiorgio 92assessed three different outpatient intervention groups for competitive employment rates after one year. Patients were not randomly assigned, which led to those who were less severely injured and more independent initially being referred more often to a less intensive outpatient program. They noted that all three groups of patients reached the same level of employment at the end of the study after undergoing therapies of different intensity. The authors suggest that patients with diverse levels of disability can make similar gains with different intensities of therapy. However, too many confounding factors exist to draw such a conclusion from this study.