Primary Care for Patients with

Brain InjuryCourage Center

Physicians Clinic

Teresa Kiresuk, DNP

Michelle Ullery, FNP

Korinne Novak, ANP

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Brain Injury Incidence

• MN TBI: 154,933 – Estimated that 10,00 progress to long term disability (MN,

Department of health, 2010)

• Nationwide TBI: 1.4 million annually – 100,000 develop long term sequale (CDC, 2010)

• Currently estimates of 5.3 million individuals have disability due to TBI (CDC, 2009)

cdc.gov/traumaticbraininjury/tbi_report_to_congress.html#6

health.state.mn.us/injury/midas/ub92/index.cfm

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Post Brain Injury Problems

Physical Symptoms

Psychological Symptoms

Social Symptoms

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Physical Symptoms

Headache Dizziness

Tinnitus Visual Disturbances

Insomnia Fatigue

Chronic Pain Impaired Cognition

Neurogenic Bladder Neurogenic Bowel

Spasticity and Dystonias

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Psychological Symptoms

Personality Changes

Mood Disorders

• Depression

• Mania

• Anxiety

• Substance Abuse

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Social Symptoms

Relationship Difficulties

Vocational Concerns

Sexuality Issues

Driving Safety

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Health Maintenance Needs

USPSTF Preventive healthcare and health maintenance

General recommendations based on age and gender for

-Screening, -Immunization

- Counseling -Chemoprophylaxis

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Health Maintenance NeedsFollowing TBI

Screening: Headache, fatigue, dizziness, visual changes, bowel and bladder management, spasticity, mood disorders, personality changes, vocational concerns and status, relationship concerns, and substance use

Counseling: injury prevention, family planning, health concerns

Immunization: pneumovax, influenza, hep b, TD,

Chemoprophylaxis: asa, vit d, calcium, bisphosphonates

Secondary Prevention Measures: injury, skin integrity,

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Health Maintenance Challenges

Inadequate comprehensive primary care and preventive health services

• Appointment time limitations

• Physical access to clinic and exam techniques

• Provider knowledge regarding Post TBI needs

• Provider knowledge regarding Health Maintenance Needs

• Focus on a Few Chronic Problems

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Interdisciplinary Approach

Primary Care, Psychiatry and PM&R in same clinic

HCH Model

Co-Visits, Back to Back Visits

Specialty Services within Clinic Organization

Rehabilitative Services in Organization

Specialty Referrals Available

Adaptive Clinic Equipment

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ReferencesBockenek, W., Currie, D. (1994). Physical medicine and rehabilitation as a primary care specialty, Commentary. American Journal of Physical Medicine and Rehabilitation. 73(1) 58-60.

Bushnik, T., Englander, J., & Wright, J. (2008). The experience of fatigue in the first 2 years after moderate-to-severe traumatic brain injury: a preliminary report. Journal of Head Trauma Rehabilitation. 23(1)17-2

Castriotta, R,& Murthy, J. (2011). Sleep disorders in patients with traumatic brain injury: a review. CNS Drugs 25(3): 175-85.

Hoffman, J., Lucan, S., Dikmen, S., Braden, C., Brown, A., Brunner, R., Diaz-Arrastia, R., Walker, W., Watanabe, T., and Bell, K. (2011). Natural history of headache after traumatic brain injury. Journal of Neurotrauma, 28(9) 1719-1725.

Iverson, G., Zasler, N., & Lange, R. (2007). Post-concussive disorder. In Zasler, N., Katz, D., & Zafonte, R. (Eds.), Brain Injury Medicine (pp373-406). New York: Demos Medical Publishing

Klein, M., (2011). Sexuality and Dysfunction. Medscape Reference: Drugs, Diseases, and Procedures. Retrieved from http://emedicine.medscape.com/article/319119-overview#a30.

Kroll, T., Jones, G., Kehn, M., and Neri, M. (2006). Barriers and strategies affecting the utilization of primary preventive services for people with physical disabilities: a qualitative inquiry. Health and Social Care in the Community, 144284-293.

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ReferencesMorrison, E., George, V., & Mosqueda, L., (2008). Primary care for adults with physical disabilities: perceptions from consumer and provider focus groups. Family Medicine, 40(9)645-651.

Orff, H, Ayalon, L., & Drummond, S. (2009). Traumatic brain injury and sleep disturbance: a review of current research. Journal of Head Trauma Rehabilitation, 24(3): 155-65.

Radice-Neumann D, Zupan B, Tomita M, Willer B (2009). Training emotional processing in persons with brain injury.  Journal of Head Trauma and Rehabilitation, 24(5): 313–323.

Slomine, B., McCarthy, M., Ding, R., MacKenzie, E., Jaffe, K., Aitken, M., Durbin, D., Christensen, J., Dorsch, A., and Paidas, C.(2006). Health care utilization and needs after pediatric traumatic brain injury. Pediatrics, 117(4)663-674.

Sutton, J., and DeJong, G. (1998). Managed care and people with disabilities. Archives of Physical Medicine and Rehabilitation, 79: 1312-1316.

US Department of Health and Human Services (2010). Agency for Heath Care Research and Quality. The guide to clinical preventive services 2010-2011. Electronic Publication of the US Preventive Ser