Facilitating Community Integration - University of … · Facilitating Community Integration Following TBI Jessica Kersey, OTR/L, CBIS 7th Annual Current Concepts in Brain Injury

Facilitating Community Integration Following TBIJessica Kersey, OTR/L, CBIS

7th Annual Current Concepts in Brain Injury RehabilitationNovember 5, 2016 1

Facilitating

Community Integration JESSICA KERSEY, MOT, OTR/L, CBIS

Community Integration

“Having something to do, somewhere to live, and

someone to love”

McColl, et al. (1998)

Community Participation

“Occurs at the intersection of what the

person can do, wants to do, has the

opportunity or affordances to do, and

is not prevented from doing by the

world in which the person lives and seeks to participate”

-Mallinson & Hammel (2010)



Community Integration

International Classification of Functioning, Disability and Health (ICF) promotes focus on participation vs. remediation of deficits

Moves focus away from specific impairments, and more toward a focus on life satisfaction and meaningful participation

Impact of environment: training and practice in a realistic setting leads to better carryover and generalization of skills

Sloan, Winkler, Calloway (2004)

Research Study

Patients discharging from inpatient rehab with primary diagnosis of

TBI, age 18-55

Outcome measures completed at admission, discharge, 90-days

following discharge, and 1 year following discharge

Total of 25 participants; 13 completed entire study

Average age: 38.4

Average length of rehab stay: 20.1 days

Outcome Measures

Outcome measures:

FIM: Functional Independence

MAPI-4: Abilities (Deficits-level), Adjustment, Participation

Community Integration Questionnaire: Home Integration, Social

Integration, Integration into Productive Activities

Satisfaction with Life Scale: Likert Scale, 5 items

Caregiver Burden Scale: Patient needs, caregiver’s perceived

burden



Results

Significant Correlations (p<.05):

Discharge FIM Score and Caregiver Tasks at 1 Year (r= -.702)

Discharge FIM Score and Survivor Needs at 1 Year (r= -.699)

Discharge FIM Score and CIQ Productive Activity at 90 day (r=.651) and 1 Year (r=.604)

Rehabilitation LOS and CIQ at 1 Year (r= -.711) as well as all 3 CIQ Subscales

Also, moderate - strong relationship between social integration and life satisfaction at 1 Year (r= .527)

Evaluation Process

Determine the client’s goals and analyze performance in

a functional context

Evaluate client and environmental factors

Participation-level assessments are best for a realistic assessment of client performance

COPM: Client-centered and can assist with goal setting

Goal Attainment Scale: Assesses performance compared to desired outcome

Wheeler, S. (2015)

Participation Level Assessments

Brain Injury Community Rehabilitation Outcome-39

Community Integration Measure

Community Integration Questionnaire

Functional Assessment Measure

Mayo-Portland Adaptability Measure-4 (MPAI-4)

Participation Objective, Participation Subjective

Participation Profile

Wheeler, S. (2015)



Components of Community Integration

1. Satisfaction and Quality of Life

2. Independence and Social Integration

3. Caregiver Burden

4. Return to Driving

5. Productivity

McCabe, et al. (2007)

Life Satisfaction/Quality of Life

Often a decline in life satisfaction initially upon discharge from inpatient

Assessment Spotlight: QOLIBRI (Quality of Life After Brain Injury)

Leisure participation impacts quality of life

Improved self-esteem, goal attainment, self-awareness, emotional well-being

Rarely address in rehab settings

Return to work: most important for quality of life

Teach productive, problem-based coping strategies

Kersel, et al. (2001)

Independence and Social Integration

Independence and social integration can impact all other

components of community integration

Social isolation one of the most distressing consequences of TBI

Relies on sufficient cognition, speech/language/conversation skills,

emotional control and self-monitoring, and ability to attend to and

follow social rules

Assessment Spotlight: Functional Assessment Measure

Often most limited by impairments with executive functioning and

self-awareness

Wheeler (2015)



Self-Awareness Assessment

Awareness Questionnaire

Neurobehavioral Functioning Inventory

Self-Awareness of Deficits Interview

Patient Competency Rating Scale

Can also use discrepancy scores on a variety of

functional assessment tools

Wheeler, S. (2015)

Metacognitive Training

Metacognitive approach:

Client estimates their performance on a task

Client completes the task

Client compares predictions with actual performance

Global strategy training (Goal-Plan-Do-Check), domain-specific strategy training

Toglia & Kirk (2000)

Individualized Skill Training

Address skills needed to achieve goals with a top-down approach

Simplify or structure the task to set the client up for success, with training on use of compensatory strategies

Build on existing strengths, or try activities that were enjoyed prior to injury for familiarity and ease of learning

Develop routines so that task completion becomes automatic; provide repetitive and consistent practice opportunities

Wheeler, S. (2015)



Caregiver Burden

Stress within the family can significantly impact the client’s

outcomes

Caregiver burden can persist years or decades after injury

Marriages are often disrupted: dependency, loss of physical

and emotional intimacy, behavioral and emotional issues,

self-centeredness

Behavioral and cognitive impairments have the strongest

negative impact on family functioning

Divorce rates consistent with the general population

Marsh, et al. (1998), Kreutz , et al. (2007)

Caregiver Burden-Intervention

Family needs to be involved in treatment, and stress level should be

frequently re-assessed to determine needs

Identify appropriate social supports: respite services, personal care

assistant, information resources, support groups

Not all assistance is perceived as helpful; resources must be

perceived as valuable and supportive by caregiver

Teach coping skills for family members

Family Needs Questionnaire- Revised, Caregiver Strain Index, Severe

Obstacles Scale

Wheeler, S. (2015)

Return to Driving

Individuals with TBI who have discontinued driving experience lower

rates of life satisfaction and community integration

Impacted by impaired memory, attention, processing speed and

executive dysfunction

50%-80% of individuals with severe brain injury return to driving

Two-thirds are never formally evaluated

Those with severe TBI who return to driving and are involved in a

crash are more than twice as likely to be at fault

Family/caregivers are the most common cause for driving cessation

Wheeler, S. (2015)



Driving Rehab Specialists

When to refer: Patient should have the potential for success in order

to preserve self-efficacy

Screen for essential skills:

Vision: Depth perception, visual field, color perception, scanning

Path-finding: Trails B

Reaction Speed

ROM, strength, coordination

Sustained attention

Safety awareness

Return to Work

Return to work is more closely correlated to life satisfaction than any

other activity

Interpersonal difficulties is the most commonly cited reason for job

separation following TBI

Other challenges: Impaired social competency, self-monitoring,

disinhibition, missed social cues, disorganized thoughts, aggression

Employment rate following TBI: 20-50%

TBI not always visible; employees often don’t get the supports they

need

Wheeler, S. (2015)

Return to Work

Self-awareness is key

Train time management, organizational skills, communication

strategies, social and cognitive strategies

Train on coping strategies, adaptive behaviors

Employer education is essential; get them engaged in return-to-work

plan

Address public transportation access, mental health service needs,

family education, and services available through state agencies

Trexler, et al. (2010)



Return to Work Programs

Vocational Rehabilitation: “Intensive individualized rehabilitation of work skills in a structured environment, guided work trials, and assisted job placement with transitional job support”

Supported Employment: “Job placement, on-the-job training, and long-term support and job skills reinforcement”

Case Coordination: “holistic rehabilitation approach that is individualized to suit the client’s specific needs”

Fadyl & McPherson (2009)

Return to School

Return to school can be limited by impulsivity, decreased self-awareness, organization, planning, sensory overload, language impairments

High risk for failure

TBI not always visible; students may not receive adequate support

Educators may not understand the cognitive and behavioral challenges associated with TBI

Wheeler, S. (2015)

Return to School- Interventions

Discussion of strengths and weaknesses

Establish specific academic and non-academic goals

Train skills for time management, studying, interaction with

classmates and teachers, coping skills

Identify supports: family, friends, counselors, disability services

Coaching, peer mentorship

End of year portfolio: outline strategies and tools that were

beneficial

Kennedy & Krause (2011)



Conclusions/Final Remarks

Community integration is a multi-dimensional component of rehab

that can be addressed at all stages of recovery

Assessments and interventions should reflect the natural

environment and natural barriers as much as possible

Family and caregiver must be involved in the rehab process

Independence and Social Integration have a significant impact on

other components of community integration

References

Barco, P., Crosson, B., Bolesta, M., Werts, D., & Stout, R. (1991). Training awareness and compensatoion in postacute head injury rehabilitation, In J. Kreutzer & P. Wehman (Eds.) Cognitive rehabilitation for persons with traumatic brain injury: A functional approach (pp 129-146). Baltimore, MD: Paul H. Brookes

Ergh, T. C., Rapport, L. J., Coleman, R. D., & Hanks, R. A. (2002). Predictors of caregiver and family functioning following traumatic brain injury: Social support moderates caregiver distress. Journal of Head Trauma Rehabilitation, 17, 155-174.

Fadyl, J. K., & McPherson, K. M. (2009). Appraoches to vocational rehabilitation after traumatic brain injury: A review of the evidence. Hournal of Head Trauma Rehabilitation, 24, 195-212.

Fisk, G. D., Schneider, J. J., & Novack, T. A. (1998). Driving following traumatic brain injury: Prevalence, exposure, advice and evaluations. Brain Injury, 12, 683-695.

Kennedy, M. R. & Krause, M. O. (2011). Self-regulated learning in a dynamic coaching model for supporting college students with traumatic brain injury: Two case reports. Journal of Head Trauma Rehabilitation, 26, 212-223

Kersel, R. C., Marsh, N. V., Havill, J. H., & Sleigh, J. W. (2001). Psychosocial functioning during the year following severe traumatic brain injury. Brain Injury, 15, 683-696.

Kreutzer, J., Marwitz, J., Hsu, N., Wiliams, K., & Riddick, A. (2007). Marital stability after brain injury. NeuroRehabilitation, 22, 53-59.

References

Mallinson, T & Hammel, J. (2010). Measurement of participation: Intersecting person, task, and environment. Archives of Physical Medicine and Rehabilitation, 91(suppl.), S29-S33.

Marsh, N. V., Kersel, D. A., Havill, J. H., & Sleigh, J. W. (1998). Caregiver burden at 6 months following severe traumatic brain injury. Brain Injury, 12, 225-238.

McCabe, P., Lippert, C., Weiser, M., Hilditch, M, Hartridge, C., & Villamere, J.; ERABI Group. (2007). Community reintegration following acquired brain injury, Brain Injury, 21, 231-257.

McColl, M.A., Carlson, P., Johnston, J., Minnes, P., Shue, K., Davies, D., &Karlovits, T. (1998). The definition of community integration: Perspectives of people with brain injuries. Brain Injury, 12, 15-30.

Novack, T. A., et al. (2010). Return to driving within 5 years of moderate to severe traumatic brain injury. Brain Injury, 24, 464-471

O’Callaghan, A., McAlister, M., & Wilson, L. (2012). Insight vs readiness: Factors affecting engagement in therapy from perspectives of adults with TBI and their significant others. Brain Injury, 26, 1599-1610



References

Sherer, M. & Sander, A. M. (2014). Handbook on the Neuropsychology of Traumatic Brain Injury. New York, NY: SpringerScience & Business Media

Sloan, S., Winkler, D., & Callaway, L. (2004). Community integration following severe traumatic brain injury: Outcomes and best practice. Brain Impairment, 5, 12-29.

Spitz, G., Schonberger, M., & Ponsford, J. (2013). The relations among cognitive impairment, coping style, and emotional adjustment following traumatic brain injury. Journal of Head Trauma Rehabilitation, 28, 116-125.

Toglia, J. P. & Kirk, U. (2000). Understanding awareness deficits following brain injury. NeuroRehabilitation, 15, 57-70.

Trexler, L. E., Trexler, L. C., Malec, J. F., Klyce, D., & Parrott, D. (2010). Prospective randomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury. Journal of Head Trauma Rehabilitation, 25, 440-446.

Wheeler, S. (2015). Community recovery and participation in K. M. Golisz & M. V. Radomsky (3rd Ed.) Traumatic Brain Injury (TBI): Interventions to Support Occupational Performance (pp 231-294). Bethesda, MD: American Occupational Therapy Association, Inc.

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Facilitating Community Integration - University of … · Facilitating Community Integration Following TBI Jessica Kersey, OTR/L, CBIS 7th Annual Current Concepts in Brain Injury