Brain Injury Professional, vol. 3 issue 2 by Nikolai Alexeev

BRAIN INJURY professional vol. 3 issue 2

The official publication of the North American Brain Injury Society

Special Issue on Life Care Planning

Setting the Standards in Life Care Planning: Be on the Cutting Edge of this Sub-Specialty Life Care Planning for the Client with a Brain Injury Certification and Training in Life Care Planning Earning Capacity Analysis: Foundations, Concepts, and Issues Residential Rehabilitation Assessments in the Development of a Life Care Plan Critical Thinking: Its Impact on Life Care Planning

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contents

vol. 3 issue 2, 2006

north american brain injury society

departments 4 Chairman’s Message 8 Guest Editor’s Message

chairman Robert D. Voogt, PhD treasurer Bruce H. Stern, Esq. family liason Julian MacQueen executive vice president Ronald C. Savage, EdD executive director/administration Margaret J. Roberts executive director/operations J. Charles Haynes, JD marketing manager Joyce Parker graphic designer Nikolai Alexeev administrative assistant Benjamin Morgan administrative assistant Bonnie Haynes

16 Conferences brain injury professional 21 Professional Appointments 44 Non-Profit News

publisher Charles W. Haynes publisher J. Charles Haynes, JD Editor in Chief Ronald C. Savage, EdD founding editor Donald G. Stein, PhD design and layout Nikolai Alexeev advertising sales Joyce Parker

46 New and Noteworthy EDITORIAL ADVISORY BOARD BRAIN INJURY professional vol. 3 issue 2

The official publication of the North American Brain Injury Society

Special Issue on Life Care Planning

features 12 Setting the Standards in Life Care Planning:

Be on the Cutting Edge of this Sub-Specialty by Paul M. Deutsch PhD, CRC, CCM, CLCP, FIALCP, LMHC 18 Life Care Planning for the Client with a Brain Injury by Susan Riddick-Grisham, BA, RN, CCM, CLCP and Robert H. Taylor MA, LPC, CRC, CDMS, CLCP 24 Certification and Training in Life Care Planning by Lori A. Allison, MA, CLCP, MSCC and Paul M. Deutsch, PhD, 28 Earning Capacity Analysis: Foundations, Concepts, and Issues by Ann T. Neulicht, PhD, CRC, CLCP, CVE, CDMS, LPC, ABVE-D and Brian Preston, MS, CRC, CLCP, ABVE-D 36 Residential Rehabilitation Assessments in the Development of a Life

Care Plan by Brian Preston, MS, CRC, CLCP, ABVE-D and Nathan Zasler, MD, FAAPM&R, FAADEP, DAAPM 40 Critical Thinking: Its Impact on Life Care Planning by Jan Roughan

Michael Collins, PhD Walter Harrell, PhD Chas Haynes, JD Cindy Ivanhoe, MD Ronald Savage, EdD Elisabeth Sherwin, PhD Donald Stein, PhD Sherrod Taylor, Esq. Tina Trudel, PhD Robert Voogt, PhD Mariusz Ziejewski, PhD

editorial inquiries Managing Editor Brain Injury Professional PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787 Website: www.nabis.org Email: contact@nabis.org

advertising inquiries Joyce Parker Brain Injury Professional HDI Publishers PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787

national office

North American Brain Injury Society PO Box 1804 Alexandria, VA 22313 Tel 703.960.6500 Fax 703.960.6603 Website: www.nabis.org Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2006 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 77219-1400, Tel 713.526.6900, Fax 713.526.7787, e-mail mail@hdipub.com

BRAIN INJURY PROFESSIONAL

chairman’s message Putting the “Heart and Soul” into Brain Injury Rehabilitation and Life Care Planning Robert D. Voogt, PhD, CRC For the last 25 years, professionals in the field of brain injury have struggled to define a model of rehabilitation that addresses the holistic needs of individuals with traumatic brain injury (TBI), as well as their life long needs. In scientific literature, this subject has been discussed and deliberated to no conclusive end. Brain injury rehabilitation was not, and is not, traditional medicine. Life Care Planning is still a new and emerging field. Yet, the core of brain injury rehabilitation and life care planning is the same as what we believe gives value to human existence, i.e. happiness, dignity, respect, growth, dedication, and community integration. Such qualities are the very “heart and soul” of each of us as individuals. Part of the healing process after brain injury consists of a “community of thriving,” one in which individuals are allowed to make contributions to their own lives and to the lives of others. To be successful, brain injury rehabilitation and life care planning must focus on critical, reallife, heart-and-soul issues. A functional model of brain injury intervention must not only focus on walking, talking, and what is “medically necessary,” but must uphold what makes us special as individuals. The focus on the being of the person, that essence that makes us each feel alive, must be at the heart of our endeavors. Independence is not about whether one can walk or talk. It is not about whether one can cook a meal or write a check. Independence has a much deeper nucleus, one that is beautifully simple. True independence is an uncluttered and pure understanding of one’s spirit and soul. A person who serves the desires of the soul develops what has been termed “authentic empowerment” (Zukav, 1989). Without the motivation of welldefined self-identity, the most essential element in designing effective brain injury rehabilitation, life care plans and independent living is missing. Aristotle, in his philosophical text of the nature of the mind and soul, explained that “ the soul is in a way all existing things; for existing things are either sensible or thinkable, and knowledge is in a way what is knowable, and sensation is in a way what is sensible: in what way we must inquire” (Aristotle, 350 B.C.) The living self is a guide to one’s world. The tools are unique and, once lost, need replacing. There are those who suggest that “quality of life” for individuals with disabilities is not as important as their ability to “get by.” Often, the criterion for the life care plan of individuals with disabilities, especially brain injury, is based on “getting by” or doing what is “medically neces4

BRAIN INJURY PROFESSIONAL

sary.” Perhaps that explains why most Americans with severe TBI reside in state psychiatric hospitals, are inappropriately placed in nursing homes or exiled in the prison system. Many are simply neglected in lonely environments without access to their community, often returning to their parents’ home and living an isolated existence away from peer groups and social opportunities. Despite the inability to return to levels of previous functioning, intervention is still considered the most valuable option for people experiencing TBI. Like someone with a hearing loss, a visual impairment or a spinal cord injury, a person with TBI can be managed with the prosthesis of a second brain. The individual with a spinal cord injury has a wheelchair, the person with a hearing impairment has a hearing aid, and a visually impaired person may have a guide dog as their prosthesis. A person with a brain injury needs another brain as their prosthesis. This is possible only when another person is available to assist them. Even those who are considered to have minor TBI often need this support due to the devastating loss of adult executive function. Just as an amputee might have a prosthetic leg or a diabetic might take insulin, in neither case a cure for the disability, any individual with brain injury must be granted the opportunity to return as close as possible to their previous life. The prosthesis does not allow the individual’s limb to grow back nor does the vial of insulin cure diabetes. Both treat the symptoms, are readily funded and are easily accepted as necessary interventions for those in need. Yet, the most pressing problem in brain injury care — the loss of quality of life — is generally not considered as part of the current managed care medical model and continues to be an undervalued component. Building a bridge to dignity, self-respect, redefinition and active participation should be the top priority for all brain injury-related professions. The most costly part in brain injury rehabilitation is the cost of a community for the individual with TBI. This can be restored in a home-life atmosphere with proper support care provided, or in a long-term care program. It is important to have the individual with brain injury become part of the least restrictive environment. However, this concept of “least restrictive” is often poorly understood. At first glance, an environment in which care providers look after persons with TBI is seen as restrictive. On the other hand, a least restrictive environment is seen as one where a person is free of supervision. The reality is that an individual who requires another person to be able to function in a number of ways in their day-to-day life, or to enhance the quality of their life, is stepping beyond their limitations. Assisted lifestyles do not imply a restricted environment. In fact, the least restrictive environment may be the one in which the person with a traumatic brain injury has assistance from another individual. This assistance will enhance day to day functioning, as well as improve overall quality of everyday

experience. Unfortunately, this replacement brain does not address the loss of what is our core.

Core of Existence In discussing the differences between human and the animal world, Cox draws an interesting parallel (Cox, 2001). Animals, in their quest for survival, bear offspring; however, humans procreate with a greater good in mind and with a more profound intrinsic value. Intimacy appears to be something shared within the human world with or without sexual relations (Kaitaro et. al. 1995; Corrigan, 1994). Intimacy is one interaction that appears to define human experience. Yet, individuals with TBI are most often not capable of true intimacy. Therefore, a basic human experience is lost. The human brain’s frontal lobes are the key in this distinction because their function is believed to control the ability to plan, to organize, to moderate behavior, to make choices and to monitor inner nature (Cox, 2001). It is further theorized that the core of human existence regulates how and when energy is expended. In more day-to day terms, this function determines the ability of every individual to be engaged in work that is not only meaningful and purposeful, but also harmonious with the development of soul and parallel to the hope of self-actualization. Functional areas of everyday living often affected by TBI are those most needed for a meaningful and productive life. Self-awareness is essential for monitoring one’s functions and for engaging and evaluating one’s relationship with others. People with TBI can destroy relationships without knowing it due to an inability to show empathy. Likewise, a lack of respect can easily disrupt the most dedicated family members and caregivers. Loving others, and the ability to sense love from others, may be tragically lost after TBI. Loving is a brain function seated in emotional experience linked to the range of all other emotions which emanate from the brain. Even changes at the cellular level, undetected by modern technology, can have far reaching consequences for individuals diagnosed with the misleading term, “minor brain injury.” We often talk about the concept of a “broken spirit.” When a spouse dies, the spirit of the remaining partner is often “broken,” which frequently translates into real physical illness. And yet, we do not address the spirit and soul of the individuals with TBI. Many teenagers, for example, experience overwhelming frustration when their parents sustain brain injuries. Parents with TBI show a dramatic lack of interest in family life. A frequent sequelae of brain injury is self-absorption, coupled with an almost childlike narcissism. This lack of interest and perceived selfishness also causes previously happy marriages to end in divorce. After brain injury, television often becomes the substitute for the careers and professionals lives that once filled 10 hours or more of each day. Unchecked, television can become a constant companion for anyone with TBI, filling the void of a broken spirit or a lost dignity. The loss of faith in one’s self remains the most staggering effect of TBI.

Incorporating Quality of Life into Life Care Planning We face an expected reality of more people living with brain injury with less care being provided to those with brain injuries at every level. No clear vision exists for accommodating people in our communities who experience long-term handicaps from brain injuries. The proposed goal through life care planning is thus to live, not just survive. Often, there is little consensus regarding the diagnosis of brain injury, the prognosis, or even the occurrence of brain injury. After years of research, clinical trials, conferences, treatment modalities and programs, lines are drawn in the sand by various camps of thought. Everyone is a winner, except for the survivor of brain injury. Thus, the challenges are now even more pronounced. Rehabilitation and long-term planning are still essential tools to help promote healing and wellness in the lives of survivors by lessening the handicap caused through injury. However, all too often the focus is only on the physical presentation. With no objective scientific evidence via MRI or PET scan, professionals declare no brain injury and discuss only secondary gains. To some professionals, average scores on neuropsychological testing suggest no brain injury. The path to establishing a plan of care with so much controversy in the field is a difficult one. It should be universally unacceptable to rely on scans and tests without behavioral observation, clinical evaluation or relevant input from significant others. The very essence of brain injury demands a patient history, a detailed intake, a recorded account from significant others, a complete review of medical, neuropsychological, social, vocational, and educational evidence combined with extensive experience and understanding of brain injury before the future can be mapped. Only after a complete evaluation can one begin to propose a comprehensive plan of care for a changed life. There are 1.4 million new brain injuries in the United States each year (Thurman et. al., 1999). Approximately 85% of these injuries are considered mild (Bazarian et. al., 2005). While the term mild would appear to lessen the seriousness, distinct problems with cognitive functioning, psychosocial issues, employment, balance, headaches and sleep challenges can cause significant handicaps and debilitating results. The National Institute of Health stated in 1999 that mild TBI should be a research priority since it presented a major public health problem (Thornhill et. al., 2000). It has been accepted for many years that severe TBI will most likely produce life long complications for survivors. More recently, a significant number of those individuals diagnosed with mild TBI have demonstrated to portray long lasting challenges (National Institute of Health, 1999). We continue to look for ways to improve the lives of those with TBI by providing acute rehabilitation, post acute care, community reentry, and even technical assistance for cognitive rehabilitation. The ever-present challenges of losing

all the cognitive functions include memory, executive function, relationship issues and psychosocial capacities. Current literature regarding cognitive rehabilitation for memory problems does not demonstrate that “restitution-oriented therapies” provide long term enhancement of memory (Robertson, 1999). Aids such as notebooks and diaries are most commonly given to survivors of TBI, although only seven percent of those given these aids were using them (Evans et. al.). Most external aides and diaries require neuro-cognitive functions that are not available in many cases to those with brain injury. Thus, a second brain as a prosthetic to provide that assistance may be a far better choice. Individuals with executive function disorders are particularly difficult to rehabilitate by their very nature. One most challenging conditions to treat is the loss of initiation (O’Connell, 2003). While technical system support may give some help to memory, the essence of losing one’s initiation again suggests the critical need for the assistance of an external brain. While we may have shown improvement in case studies and small samples, professionals face long-term challenges reaching those individuals with no access to advanced care and translating the long-term benefits of external care systems.

The Subtleties of Brain Injury The damages caused by brain injuries are not always visible, not always immediate. A better understanding regarding the subtleties of brain injury outcomes must be explored as a look beyond the obvious. Objective testing does not always measure the brain damage that is so clearly devastating to the person. A replacement value for lost capacity and function in one’s life is not easily defined. To ascertain long-term damage in brain injury cases is, first and foremost, an educational process. When considering the life span of an individual with a brain injury, medical intervention represents a mere five percent of lifetime costs – a relatively insignificant part of the long-term care continuum. Brain injury is a psychosocial, behavioral and relationship issue and, in most cases, after a brief period of initial involvement, brain injury moves beyond the medical realm. Typically, the traditional effects of disabilities are well understood and regularly funded: problems with ambulation require the expertise of a physical therapist; speech therapy is recommended for communication disorders; employment issues are addressed by a vocational counselor; occupational therapy can help address the activities of daily living. The standard view of damages as being caused by specific injuries, resulting in specific physical problems, calling for specific remedies is easily grasped and, on the face, makes sense and seems sufficient. But, in brain injury cases, life care planning must also encompass the totality of brain activity – not just the body. The complex reality of brain injury rests on psychosocial disabilities and disabling complications that are frequently overlooked. Personhood is one component that most significantly changes

in people with brain injuries, requiring much more rehabilitation than a mere physical intervention. The brain defines individual uniqueness and quality of life for each person’s identity. Characterized by more than mobility, speech capacity, enjoyment of a good meal or a satisfying nine-tofive job, the core of a person shapes the life of the self. How is quality of life addressed and how can payers be convinced of the importance in funding relationships and experiences? Establishing needs in brain injury begins with the acknowledgment of personhood. Does a person with quadriplegia need a wheelchair? Yes, though a person with quadriplegia certainly does not need a wheelchair to process information mentally or to bond emotionally with others. The need for a wheelchair is very specific – to replace the person’s former ability to walk. Personhood – the trait that separates humans from animals – is not impacted by use or non-use of a wheelchair. Does a person with a brain injury need a brain? Loss of brain function must be replaced somehow, just as a person with a spinal cord injury uses a wheelchair to counteract the inability to walk. In fact, replacing a lost brain is even more crucial, given its control over the psychosocial-emotional areas of life. If lost mobility is compensated by the use of a wheelchair, then lost brain capacity is compensated by… what? For people with brain injury, an “alternative brain” is often necessary to achieve a meaningful life – a life that closely mirrors previous existence. Another person might be needed to assist an individual with a brain injury by providing lost skills. Skills add worth to the person, thereby helping to repair the loss to the person, to the household and to the greater community. Most ten to eleven year olds are independent in activities of daily living. They dress, bathe, study, get ready for school within a structured family environment and with cues. They often can make a sandwich, microwave and make change at the store. But, they are not endowed with full development of insight, judgment or advanced executive skill to live alone. They need another person to assist them, to provide guidance and structure. Such leadership is called parenting. Parents are prostheses for children, ensuring safety, engendering independence and allowing the growth of personal wishes and desires.

Practicalities of Life Care Planning By providing a second brain to a person living with TBI, a life care planner by necessity addresses the need for organization, information control, initiation, routine, memory and structure. The task of placing a dollar figure on costs associated with this approach becomes slightly less complicated when viewed as an extension of the analogy to a prosthesis. A person who is hearing impaired uses a prosthetic device, namely a hearing aid. A person who is visually impaired can benefit from a seeing-eye dog – another prosthetic device. Individuals who lose an arm or a leg regain functional abilities through integration of a prosthetic limb. A person with brain injury requires another individual to BRAIN INJURY PROFESSIONAL

serve as a cognitive prosthesis. Life care planning is best performed by a qualified, experienced professional in rehabilitation. In addition to projecting life care needs, the rehabilitation profession provides oversight and responsibility for all aspects of care and makes critical recommendations for the supporting levels of care throughout the rehabilitation process. Education, experience and a professional understanding of brain injury are essential. With the loss of the executive functioning of the brain, the most common symptom of TBI, individuals cannot process information in the same way. They cannot learn from mistakes, nor can they make a pot of coffee, decide what to wear, plan a business meeting, or love someone close to them. A support person, or life coach, is the remedy for an enhanced lifestyle and potential growth. During the comprehensive evaluation performed by a life care planner, all handicaps and needs of the injured person are weighed with the supporting family in mind. Beginning with preinjury status of the person with TBI, an evaluation must include his or her educational and vocational achievements, personal goals, recreational and leisure skills, personality factors, relationships, and behavior patterns. The stress and strain on the family unit often becomes apparent. Interviews reveal instances or potentials for isolation, neglect, illness, abuse, and emotional turmoil involving each family member. It is not uncommon for family members to report depression. In addition, the immediate caregivers in the family are often the first targets for the injured person’s verbal and physical aggressiveness. Thus, the physical safety and emotional wellbeing of family members are significant considerations. Quite often, families describe the personality change as far more challenging than the physical or cognitive change. The ability of the family to function as a whole, in a variety of areas, becomes stressed (Gan et. al., 2002). Life care planning also upholds the thorough review of every pertinent medical record as essential. Medical records obtained and reviewed include documentation of emergency medical interventions, comprehensive hospital records, initial injury reports, subsequent hospitalizations and outpatient services rendered by clinics. Private physicians’ records, therapists’ records, inpatient treatment program records, and school records — both pre-injury and post-injury — should also be collected and carefully reviewed. Life care planning has become pivotal to establishing the long-term care needs and the costs associated with meeting these needs. There are, however, ill-conceived life care plans available that focus on restricting costs while ignoring needs. Contrary to an authentic life care plan, this sub-standard approach is a cost containment effort made for damage control. Typically, these so-called life care plans only attempt to meet basic needs for the individual rather than truly enhance the quality of life. Yet, this alarming trend remains popular in the current managed health care environment. Through the years, many physicians, thera6

BRAIN INJURY PROFESSIONAL

pists and families have attempted to put together the necessary services that would allow individuals with a traumatic brain injury to live within their family unit or in a community-based setting. Those needs, as defined by the experts, often vary between what is basic to survival and what is required to maintain quality-of-life issues. Traditional traumatic brain injury treatment has not focused nearly as much on social issues or activities that enhance the quality of one’s life, but rather rested on the belief that treatment must primarily address the physical needs of an individual. Evolved care, while expanding, has lacked a mainstream movement to address the ongoing nonphysical needs of a person within a social setting. The goal must be living, versus surviving. A life care plan, implicit by its name, must therefore provide quality of life issues beyond the structure of day-to-day life for the individual with a traumatic brain injury. This aspect of care extends from simply walking, talking and eating to nurturing the emotional and spiritual components of any healthy adult life. Typically, the array of emotional, behavioral, and cognitive difficulties restricts individuals from independence far more than the physical sequelae. Support care is not only required for safety reasons, but becomes a necessary factor in defining the best lifestyle opportunity for individuals wanting to experience their full potential. Often, life care plans limited by cost containment/damage control reports attempt to put individuals with brain injuries in nursing homes or group homes that deny them access to community. Other times, living situations are confined to family housing. It is imperative in any quality care structure that the integrity of the pre morbid roles of the family is preserved. Without good judgment, impulse control, and the ability to organize and structure one’s life, some persons with TBI require 24-hour-per-day care. If the individual with brain injury is supported and cared for in a nurturing environment then the individual’s potential can be enhanced and healthy adjustments made. Voogt and Roussel (Voogt & Roussel, 1996) conducted a research project to examine longterm outcomes following traumatic brain injury. Individuals who had experienced a traumatic brain injury, with a minimum two-year period of post-injury, were identified. Of the 105 people who participated in this survey, 71% of the participants lived with their families, 16% lived in a facility, eight percent lived alone, and five percent lived with a roommate. Of the general population older than 25, only five percent lived with their parents or an older relative, while 24% of the subjects within this surveyed group lived with their parents or older relative. Moreover, Voogt and Roussel found that, prior to their injuries, 54% of the participants had full-time jobs, nine percent held part-time jobs, 31% were students, one percent were retired, and five percent were unemployed. After the injury, 55% were unemployed, 18% considered themselves retired, 10% were students, 14% had parttime jobs, and three percent held full-time jobs.

Two-thirds of those who considered themselves retired were younger than 65. Although some studies indicate the prognosis appears to be more optimistic when the person with the brain injury has received post-acute neuropsychological rehabilitation (Ezrachi, 1991), (Prigatano, 1995), Voogt and Roussel conversely found that receiving comprehensive rehabilitation did not significantly affect employment status (Pvalue = 0.818). In fact, those who received comprehensive rehabilitation were slightly less likely to be employed and more likely to consider themselves retired. For individuals who did receive comprehensive rehabilitation, 15% were employed, 20% considered themselves retired, 48% were unemployed and not seeking employment. For those who did not receive comprehensive rehabilitation, 21% were employed, 15% were retired, and 52% were unemployed and not seeking employment. Conclusively, there is a significant relationship between structure and activities. Voogt and Roussel found that people involved in a structured rehabilitation program are more likely to be involved in outside activities (P=0.004). Of those involved in a structured rehabilitation program, 78% reported participation in outside activities at least once per week. Of those not involved in a structured program, only 40% reported participation at that level. Of those who have never received comprehensive rehabilitation, only 28% report participation in outside activities at least once per week. Of those currently receiving cognitive remediation, 82% reported participation in outside activities at least once per week.

Advocacy of the Life Care Plan Support care with a life coach or a prosthetic brain becomes the single most expensive item in long-term care of individuals with traumatic brain injury. It has become the battle ground in determining how much care to provide for what type of need involved. There is no magic appliance such as a wheelchair that can replace missing skills, fill the void of emotions or guide the independence of one’s life. A paraprofessional, providing supportive care for an involved life, becomes a prosthetic device for the individual living with brain injury. It is imperative to understand the complexity of traumatic brain injury when planning for longterm rehabilitation, just as it is equally important to articulate specifics of long-term needs and related costs. Life care planning establishes a future path and certain goals as an answer to the difficult question of healing amid the devastation of TBI. Brain injury shatters one’s ability to function in life, thereby creating a desperate need to replace life and all its aspects. Survivors of TBI can again find quality of life through a life care plan and a spokesperson to tell the story. All losses in brain injury cases have value – both those that can be readily seen and those that cannot. Traditional care and societal custom are enemies to those individuals with TBI, forever placing limits and restrictions on a disability. However, the life care plan approach offers creative and effective results for a deserving population. The body of thought used to treat individuals

with TBI strikes an empathetic chord of humanity’s fundamental needs and collective desires. The necessity of living resides in each of us, disabled or not. The logical concept of a person as a prosthesis will advance brain injury care, elevate thinking and move all parties involved toward absolute equity and maximum potential. Robert D. Voogt, PhD, CRC Related concepts and ideas addressed in this article have been previously published by this author in various forms.

About The Author

Robert D. Voogt, Ph.D., C.R.C., is President of Robert Voogt & Associates, Inc., a rehabilitation consulting firm in Virginia Beach, Virginia, specializing in the development of life care plans and future cost analyses for individuals with all types of disabling brain conditions. In addition, Dr. Voogt is the owner of Neurological Rehabilitation Living Centers Louisiana and Virginia, and continues to design communities developed especially for brain injury populations. Dr. Voogt and his staff also offer case management services, counseling, and research.

References

Aristotle, Text outlining philosophy of mind and the soul of living creatures. De Anima. III (8), 350 B.C. Bazarian J.J., McClung, J., Shah M.N. et.al., Mild traumatic brain injury in the United States, 1998-2000. Brain Injury. 19 (2): 85-91, 2005. The Center for Disease Control and Prevention, National Center for Injury Prevention and Control, 2004. Corrigan J.D., Community integration following traumatic

brain injury. Neurorehabilitation. 4: 109-112, 1994. Cox R., Issues of the Soul. Sanford, FL: Synchronicity Press, 2001. Evans J.J., Needham P., Wilson B.A., Brentnall S., Who makes good use of memory aids? Results of a survey of people with acquired brain injury. Journal of the International Neuropsychological Society. 9 (6): 925-35, 2003. Ezrachi O., Ben Yishay Y., Kay T., Diller L., Predicting employment in traumatic brain injury following neuropsychological rehabilitation. Journal of Head Trauma Rehabilitation. 6: 71-84, 1991. Gan C. and Schuller R., Family system outcomes following acquired brain injury. Clinical and research perspectives. Brain Injury. 16 (4): 311-322, 2002. Kaitaro T., Koskinen S, Kaipoo M-L., Neuropsychological problems in everyday life: a five year follow up study of young severely closed head injury patients. Brain Injury. 9: 713-727, 1995. National Institute of Health, NIH consensus development panel on rehabilitation of persons with traumatic brain injury. Journal of the American Medical Association. 282: 974-83, 1999. O’Connell M.E., Mateer C.A., Kerns K.A., Prosthetic systems for addressing problem with initiation, guidelines for selection, training and measuring efficacy. Neuro Rehabilitation. 18: 9-20, 2003. Prigatano G., Klonoff P.S., O’Brien K.P., et.al., Productivity after a neuropsychologically oriented milieu rehabilitation. Journal of Head Trauma Rehabilitation. 9: 91-102, 1995. Robertson I.R., Setting goals for rehabilitation. Current Opinions in Neurology. 12: 703-708, 1999. Thornhill S., Teasdale G.M., Murray G.D., et.al., Disability in young people and adults one year after head injury. Prospective cohort study. British Medical Journal. 320: 1631-5, 2000. Thurman D.T., Alverson C., Dunn K.A., et.al., Traumatic Brain Injury in the United States health perspective. Journal of Head Trauma Rehabilitation. 14: 602-15, 1999. Voogt R., Roussel L., Effectiveness of rehabilitation services on survival roles following traumatic brain injury. Brain Injury Association 15th Annual National Symposium. Dallas, Texas; November, 1996. Zukav G., The Seat of the Soul. New York, NY: Simon and Schuster, 1989.

More than

Traumatic Brain Injury Serving the community for two decades, Beechwood has expanded its TBI offering to encompass broad neurological services as well as new Behavioral Remediation and Late Adolescent programs. In addition to TBI, we serve individuals with brain damage due to: • Anoxia/Hypoxia due to drowning, heart attack, drug overdose, alcohol poisoning, anesthesia errors, etc.

• Electric shock/lightning strike • Degenerative diseases • Infectious diseases • Early stage moderate dementias • Tumors • Brain surgeries • Many neurological disorders

• Stroke For information and admissions, call 1-800-782-3299. Our facilities are adapted to accommodate all levels of accessibility.

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          

                                                     

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guest editor’s message The other day I was meeting with a local physiatrist when I heard laughter coming from an office down the hall. It was a laugh that I recognized. A hoarse crowing laugh, that seemed to go on and on. As I stood listening I realized why the laugh was so familiar. It belonged to Annie, a client I met over fifteen years ago. When I first met Annie she was lying in a bed on the rehabilitation unit having just been transferred from an acute care treatment facility. Two weeks prior she had been involved in a motor vehicle accident while en route to a family event. In the accident Annie sustained a severe traumatic brain injury and her prognosis was grim. I clearly recall the look of sadness and fear in the eyes of Annie’s parents as they watched over their beautiful and once vibrant daughter who was now unresponsive to their touch. They were confronted with discussions involving medical terminology that was far beyond the scope of their understanding, and complex decisions regarding their daughter’s life. While they were thankful that she had survived the accident they were beginning to come to the realization that their lives had been forever changed. As Annie began to emerge from her coma her family was at a loss of how to deal with her agitation and anger. They soon began asking questions about the future. • What does it mean? • How will she function? • Will she be able to live independently? • Will she be able to return to work or go to college? • Will she be able to make her own decisions? • How will this affect her ability to have friends and other relationships? Sound familiar? As brain injury professionals we’re all too familiar with these types of questions. And it isn’t just the client and family asking these questions. Insurers, attorneys, and others must assess the full impact of the injury including issues such as future medical and therapeutic needs, loss of employment and the capacity to earn wages as

BRAIN INJURY PROFESSIONAL

well as a need for personal assistance. In the early 1980s, after years of providing case management services to individuals with complex medical conditions, Drs. Paul M. Deutsch and Horace Sawyer introduced the concept of life care planning as a process for development of a comprehensive plan which delineates the costs of the resources needed to meet the individualized lifelong needs of the client. This systematic, organized approach considers the patient or client, the disability, the clinical team and service providers, and the family, and takes into account phase changes in needs that occur over time as the client with a disability ages. Now twenty years later, the concept has not changed, but the scope of the process has broadened and the protocols more formalized and technical. In many rehabilitation settings, life care plans are utilized as discharge plans. Life care planning principles are now being applied to geriatric and pediatric populations. In the forensic setting, life care planners translate medical and rehabilitation concepts to education about the future needs of an individual with a disability to laypersons who sit on juries. Workers’ Compensation insurance companies utilize Life Care Plans as a tool for pro-active, outcome oriented case management. Some who know me would suggest that I am passionate about my work. I am. I have seen first hand how a life care plan, when utilized by families, clinical providers and caregivers can improve outcomes by integrating the clinical interventions, enhancing efficient utilization of health care dollars and improving communication and collaboration to ensure shared decision-making and expectations. I am very pleased to be asked to serve as the special editor of this important issue on life care planning. Dr. Paul Deutsch brings us up to date on the progress of the evolving sub-specialty practice of life care planning by discussing current research methodologies or principles. Robert Taylor and I give an overview of the methodology utilized by experienced life care planners. We also discuss some of the complex challenges of creating plans for individuals with brain injuries. Lori Allison describes the national certifications and primary educational programs available to professionals who are interested in pursuing advanced training in life care planning. Dr. Ann Neulicht and Brian Preston offer an overview of the vocational assessment process used by rehabilitation counselors, including factors to consider in selecting a vocational

rehabilitation professional, discussion of the vocational expert’s role in litigation, as well as review of evaluation and outcome issues specific to brain injury, including loss of competitive edge. Brian Preston teams with Nathan Zasler, MD to discuss how specialized community-based ABI programs can serve as excellent resources for life care planners. Jan Roughan creatively explores the question “why are there differing opinions, different Life Care Plans, given the same case.” In closing I’d like to finish my story about Annie. Thirteen years ago I formulated a Life Care Plan for her and her family. With input from them, the treating clinicians and her community supports we outlined her future needs. Whereas at one time the family was exploring the option of sending Annie to a nursing home where they thought she could get the needed care and support to ensure her health and well being, we outlined a plan that if implemented resulted in a more independent, less restrictive setting living setting for Annie. Today she lives in an apartment with a part-time caretaker who has been with her for over 10 years. She is an active part of her community and looks to the future with great optimism and joy. Her family recognizes that although this is not the life they once planned for their daughter, she is living up to a “new” potential and enjoying her life. Susan Riddick-Grisham About the Guest Editor

Susan Riddick-Grisham has greater than 25 years of experience working with patients, families and clinical teams. Known for her skills as a catastrophic injury nurse case manager, Susan is also a nationally respected figure in the Life Care Planning community. In 1992 she participated in the development of the first comprehensive national training program for life care planners. Her passion for assisting individuals with chronic disabling health conditions continues to drive the development of innovative educational programs. These programs enable Susan’s colleagues to better serve their clients and families. In addition, Susan is a frequently requested life care planner, consultant, speaker, author, and mentor. Susan is the Founder of The Care Planner Network, an online community which is dedicated to improving the reliability and validity of the life care planning process by narrowing the variance in practice patterns, and by providing resources and networking opportunities to all practicing life care planners. She is also President of Life Care Manager, LLC which provides care manager and life care planning services on a national level.

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Setting the Standards in Life Care Planning: Be on the Cutting Edge of this Sub-Specialty by Paul M. Deutsch PhD, CRC, CCM, CLCP, FIALCP, LMHC Abstract This forward to Brain Injury Proffessional’s special issue on Life Care Planning will review minimum requirements for qualifications, meeting the steps for completing the process of Life Care Planning and finally developing the necessary foundations for the plan. Each planner must take responsibility for meeting the core curriculum requirements for Life Care Planning and should consider learning the core curriculum requirements for case management or consulting with a case manager. A review of the steps in the process of Life Care Planning is provided. Finally, establishing a Medical, Rehabilitation, Case Management and Psychological Foundation for the Plan is a critical requirement in meeting today’s standards. This forward reviews the steps in accomplishing that goal. Practice in the sub-speciality of Life Care Planning has evolved into a highly sophisticated and technically complex responsibility, which should not be taken on by those lacking in training. This training must be in two separate but equally significant areas. First it must meet the core curriculum requirements outlined by one of the certifying bodies in Life Care Planning, such as the Commission on Health Care Certification, (CHCC). Whether one chooses to proceed on to certification or not does not preclude the fact that these core requirements were developed after long consideration by leaders in Life Care Planning research and education, and subsequently by research undertaken by CHCC in establishing their criteria for certification and testing. Certifying boards such as those associated with Nursing, Physicians, Psychology and Vocational Rehabilitation which may represent the original training of the professional do not provide any certification in Life Care Planning nor do they represent themselves in any fashion as providing such. Next, it is critical that the individual completing the Life Care Plan be able to demonstrate the background and training necessary to show a 12 BRAIN INJURY PROFESSIONAL

knowledge base within the disability being considered. Multiple citations, (Deutsch and Sawyer 1995; Weed 2004; IALCP 2000), refer to Life Care Planning as being transdisciplinary in nature. In doing so the suggestion is that those in practice in this sub-speciality come from a variety of backgrounds. In fact, there is a second definition to transdisciplinary that applies to Life Care Planning. Within each plan a specific disability is confronted. Each disability involves a wide range of disciplines. The Life Care Planner must interact with and consider many different medical specialist and health care professionals, along with a broad range of technologies. There are many case management issues, rehabilitation issues and often psychological issues. No single physician, regardless of speciality, no single nurse regardless of background, no vocational rehabilitation counsellor, rehabilitation psychologist or any other health care professional in Life Care Planning is in a position to complete a Life Care Plan independently. Each Planner must have the necessary training and qualifications within Life Care Planning, as well as be prepared to establish the fundamental foundations required, supporting the various components of the plan. Although it is true that the Commission on Rehabilitation Education, (CORE), which accredits Public and Private graduate school programs in Rehabilitation, has recently added a required component in Life Care Planning, this has not been a long-standing part of most educational programs. In establishing credentials in a courtroom, most Life Care Planners would be vulnerable to questions about whether they received any training in this subspeciality in their Master’s, Medical School, Nursing or other professional training programs. The same is true regarding questions about case management. To meet the standards for being qualified as a Life Care Planner it is necessary to be able to demonstrate that you met the core curriculum requirements for one of the board certification programs currently available.

It is also necessary to show that you have maintained continuing education Medical Foundation requirements even if you did not choose to pursue board certification. If The first step in the process is establishing the Medical Foundation for the the right questions are asked and you cannot provide these answers, you plan. This begins almost immediately upon referral of the case. The Life Care will be vulnerable. If you do not know the core curriculum requirements Planner should have an idea from the start of the type of records to request of these organizations, you need to become familiar with them. If you do based on the disability, age of onset, number of months post onset at time of not know the organizations in Life Care Planning that publish Standards referral, and how far into a suit the case has progressed. In the latter instance and Ethics, you need to become familiar with them. If you are unfamiliar this information should give insight into whether depositions have been taken with the Ethics rules or the Standards, you are further vulnerable to cross-ex- and experts have been disclosed. amination. This is information fundamental to the sub-speciality in which From the very beginning of the effort to summarize medical and health a Life Care Planner is choosing to practice, yet few seem to have made related professional records, an effort must be made to keep in mind how the themselves familiar with this information. The result is a treasure trove of information in those records would link to potential recommendations in the cross-examination questions that are most effective in creating problems for plan. This may occur in two ways. Recommendations from current records the planner. Appropriately, it can go much further than just problems on that have yet to be undertaken can translate to direct recommendations in the cross-examination. plan. Second are historical statements in the record that support recommenIn two Federal Appeals Court rulings physicians brought in to testify as dations that the planner should consider. An example is a history of multiple Life Care Planners have been excluded because of their lack of training in decubitus ulcers with repeated statements in the hospital and rehabilitation that field. Most recently in the United States District Court for the North- center records that poor nutrition is compromising healing and skin integrity. ern District of Mississippi Eastern Division in Jeremy A. Pharr versus Ford Listing these comments in a bullet point chart provides support for a recomMotor Company (Civil Action NO. 1:02CV252-JAD), the judge excluded mendation for a nutritional evaluation once or twice a year for your spinal the testimony of the treating internist as a direct violation of F.R.E. 702 and cord patient. Daubert. The next step is the clinical interview and history with the patient. ConIn filing a motion to exclude his testimony, the following arguments ducting this with the medical summary by your side, (or side by side with your were made. The doctor, an internist, and the patient’s treating physician questions on the computer screen), allows for a discussion of discrepancies took on the task of completing a Life Care Plan. The argument was made with the patient and family. It also allows for improved family input on their that the doctor had no training in Life Care Planning. Such training was not understanding of discussions with the physicians regarding future recommenpart of his medical training. He had not received training consistent with dations and procedures. the core curriculum requirements of the CHCC. He had never completed On completion of the medical summary, bullet point chart and patient/ a Life Care Plan prior to this plan. He admitted in proffered testimony that family interview, three steps are to follow in close proximity. The first is to he was unfamiliar with the Standards or Scope of Practice published by the establish a list of questions for each of the medical doctors and health reInternational Academy of Life Care Planners. In fact, he was unfamiliar lated professionals on the treatment team. These reports are never written with either IALCP or CHCC. He adwith a Life Care Plan in mind. These mitted he had no background in case The need to document each step in the process and the professionals rarely think of long term management, counseling, psychology, requirements for establishing the necessary Medical, outcomes or needs. These questions or any of the medical specialties associshould not rehash items in their reports Rehabilitation, Case Management and Psychological ated with the disability or involved in unless clarification is necessary, but Foundations has become critical to formulating an the disability, and he had not talked to effective, accurate, reliable and valid Life Care Plan. should focus on future needs through the treating doctors or health related life expectancy. Keep the questions to professionals. By not following the published standards, methodologies, the individual area of expertise of the health care professional to whom your tenets or principles, his plan was neither reliable nor valid. Based on these are writing. Try not to overlap into your area of specialty. The answer may rearguments, the Judge found him unqualified as a Life Care Planner and did sult in a controversial response, which compromises an opinion you are more not allow his testimony in this area. qualified to provide. In Fairchild v. United States, 769 F.Supp. 964 (W.D. La. 1991), a sisWhile awaiting the responses from the treatment team, begin the research ter district court in the same circuit ruled on this very issue under similar on clinical practice guidelines and the most current literature on the disability circumstances. Therein, the court found that a Life Care Plan prepared by involved in your plan. This may be used for further recommendations, but a physician was unreasonable and that the physician was not qualified as a most importantly it is used to support the recommendations provided by the Life Care Expert since he had attended “merely two seminars on rehabilita- treatment team or made through your own expertise. tive counseling,” and despite the fact that he had done twenty-five life care A valuable tool for the Life Care Planner is to establish a network of conplans. Id. at 968. sulting medical specialists. Often a patient has not seen members of their treatment team for some time or is only being followed by a limited number The Process of Life Care Planning of the team members because of the time since onset of the injury. In those Historically Life Care Planning has always been discussed as a consistent instances, many team members will not respond to inquiries or will indicate methodology, (Deutsch and Sawyer, 1995; Weed, 2004). That concept has they have to see the patient for an update. The consulting specialist can be not changed in 2005, but the process has grown broader in scope and more extremely helpful in answering questions after reviewing your basic narrative, technical. The need to document each step in the process and the require- medical summary and initial recommendations. ments for establishing the necessary Medical, Rehabilitation, Case Management and Psychological Foundations has become critical to formulating an Case Management Foundation effective, accurate, reliable and valid Life Care Plan. Most critical is deter- The next step in the process is establishing a case management foundation. mining what recommendations require a Medical versus Case Management, If the planner is not a board certified case manager or at least board eligible, versus Rehabilitation, versus Psychological Foundation. There are those in- they should consider consulting with a case manager. It is typically the case dividuals who profess that they are qualified to independently support each manager who is involved in implementing all of the categories of a Life Care and every item. There are still others who argue that every item requires a Plan. They arrange for durable and replenishable medical supplies, coordinate statement of medical necessity even if it is not, fundamentally, a medical admission into rehabilitation programs, arrange for home health services or recommendation. For purposes of most Life Care Plans, particularly out- implement private hire programs for aides or nurses. Those who feel they can side of Worker’s Compensation, it is necessary to utilize a team approach in determine the skill level and number of hours of home care services without the sense that the planner takes steps to obtain input from multiple sources. ever having been involved in case management, may find that they are surprisThe manner in which this should be done is covered in this section. ingly lacking in qualifications. BRAIN INJURY PROFESSIONAL

The steps involved in establishing a case management foundation are very straightforward. They begin with a careful review of the medical records for all case management notes and all references to information that will influence case management decisions. Direct written questions to the case manager on the treatment team if that individual remains current with the file is always a valuable asset. Questions to the treatment team that influence case management outcomes should be initiated. Developing clinical practice guidelines and research literature relevant to case management decisions and recommendations should be established. Rehabilitation Foundation The rehabilitation foundation begins with a review of all of the records from the relevant programs and professionals in the patient’s history. It is important to glean the progress made by the patient, levels achieved and the potential for further progress. Is further inpatient or outpatient rehabilitation justified based on the records reviewed? Is there support from the treatment team or the consulting specialist you have written? Is there support through the clinical practice guidelines and research literature? Having obtained the written responses from the treatment team and the consultants, as well as reviewed the clinical practice guidelines, it is important not to forget that for most planners this is an area that is fundamentally a part of their expertise. Do not leave out your own experience, training and background in decision making at this level. At the same time, do not dramatically exceed standards, guidelines, and research. They are there for a reason and represent the considered opinion and expertise of many professionals from a cross section of fields that have worked to establish this reference material. At the same time, it is important to get to know them thoroughly. Know what they say and what they do not say. It is extremely important not to err in one direction or another, as a result of a misinterpretation of this material. Psychological Foundation It is the rare disability, severe enough to require a Life Care Plan that does not result in psychological consequences to the patient and/or family to some degree. Whatever the recommendation, it will be necessary to establish a sound foundation in this area as well. This also begins with reviewing the patient’s medical and health related professional records for any indication of psychological response or treatment, as well as evaluations at various stages of development post onset. If qualified, writing for the original raw test data is also appropriate. This would not be necessary or appropriate if the planner is not qualified to interpret these. Writing to the psychologist with questions would be appropriate, and the more recently the patient was seen the more important this becomes. If the patient continues to demonstrate psychological problems and has not been seen in some time, then requesting an update or initial evaluation before issuing a Life Care Plan is appropriate. Let the psychologist know the kinds of questions you will need answered based on the type of disability, severity of disability, age of onset, and current age of the patient. Any other relevant facts that will guide you in developing your questions should be considered. As with the other areas of foundation, the above is followed by pulling all relevant clinical practice guidelines and current literature to aide in developing and supporting recommendations. Two schools of thought have developed among Life Care Planners on presentation of the Clinical Practice Guidelines and Research Literature. There are those who integrate these directly into the plan with links to each relevant recommendation. Other planners simply keep the relevant Guidelines and Literature in their files to reference at deposition or trial. Although I prefer the former, it is up to each planner to determine the approach, but the use of Guidelines and Literature has become a critical component of Life Care Planning. An Evolving Sub-Specialty Life Care planning remains an evolving sub-specialty in much the same way as any medical or health related profession. This is, in part, driven by the evolving nature of the treatment specialties that interact with the disabled and whose professions are undergoing constant change through research. Yet the process of Life Care Planning is also undergoing a necessary and constant ex14 BRAIN INJURY PROFESSIONAL

amination of its processes as research helps refine the accuracy of the steps and provides greater foundation for the conclusions that are drawn. Toward this end, in 2001, The Foundation for Life Care Planning Research was formed. The goal of the Foundation is to promote and support research on the reliability and the validity of the Life Care Planning Process. The Board of the Foundation and the research committee define this goal very broadly and in doing so have supported a number of Doctoral Dissertation students, Masters Thesis, University based projects, private sector practitioners and conducted research directly through the Foundation. The Foundation has a half time research Director, Sherie L. Kendall Ph.D. with a degree in medical neurobiology. She was the first graduate of the National Institute of Health’s bench science to clinical research training program and is partially supported through a NIH grant for loan repayment program. Through the Foundation an increasing number of projects have been completed through complete or partial support. The following are important examples. The 2002 paper on reliability and validity of the Life Care Planning process conducted by Amy Sutton, et. al. completed a statistical analysis of life care plans done after an original patient evaluation and one subsequently completed after a full re-evaluation of the patient one to five years later. The Foundation later stepped in after reviewing a qualitative assessment completed by Doreen Casuto and invited her to subject the same study to a much more rigid statistical analysis with the assistance of Dr. Kendall. This resulted in a publication, (Kendall & Casuto, 2005), in which a follow-up survey on a life care planning patient load was quantitatively assessed for reliability and validity. Currently the foundation has just completed a replication study of the Sutton, et. al., research which will be submitted for publication in the first quarter of 2006. Ongoing research into the reliability and validity of the process of life care planning is essential but even more is necessary. The following examples provide further insight into the nature of the work that is being done and the creative nature of the research that is essential to the future growth of life care planning. Jamie Pomeranz Ph.D. completed his doctoral dissertation in 2005 with partial funding from the Veterans Administration and The Foundation for Life Care Planning Research. His work, “Personal assistance services for individuals with spinal cord injury: Life Care Planning Implications”, is original and provides an important foundation for planners interested in giving substance to their thought process on this critical area of planning. The Foundation gave its 2005 research award to the, (Marini and Harper, 2005), work on “Empirical validation of medical equipment replacement values in life care plans”. This work gives important and immediate foundational support to specific categories in the Life Care Plan. Two of the more recent projects include, (Deutsch, Kendall, et. al., 2005) in which vocational outcomes in traumatic brain injury were examined during a research project specifically undertaken to examine reliability and validity in Life Care Planning. This demonstrates to the Life Care Planning community that while surveying a patient population, the opportunity can be taken to collect data that can support multiple statistical analysis and publications that can benefit the professional community. The final project to be chosen as an example is Technologies Impact on Life Care Planning, (Deutsch, Kendall, et. al. 2005), a first statistical examination of the impact of both replacement technology and new technology on rising medical costs and the impact this has on selected Life Care Plan categories. The results suggest that five of the seven selected categories are most certainly being impacted by technology and appear to be growing at a compound average annual growth rate above inflation based on the CPI category for that section of the plan. This is a first of its kind pilot study and the paper points out the limited applications of its conclusions and a number of additional research studies that must be done. For the first ten to fifteen years of its existence Life Care Planning developed through a natural evolution as it was applied by more and more professionals, particularly in the case management process. Over the past ten years it has been subjected to an increasing amount of scientific research. Although case studies and qualitative analysis are still worthwhile, this subspecialty cannot survive over time without being subjected to the kind of scrutiny that comes from scientific analysis of its process, foundations and assumptions. The Life Care Planner does not have to fear that they will lose

individual professional choices as a result. Physicians have clinical practice guidelines and standards of care. Nevertheless they have to make critical, individual choices every day based on the unique aspects of the patient and the injury or disease process. Life Care Planning is now different. This research will refine the process, build the practice guidelines, improve the standards already being developed and bring increasing respect to the sub-specialty as a whole. It will also make it increasingly difficult for those who wish to just stand up and declare themselves Life Care Planners without bringing themselves in-line with the basic requirements. Conclusion As a sub-specialty, Life Care Planning has become attractive to many Health Care Professionals. The majority have made the informed decision to obtain training and proceed cautiously as they develop the skills necessary to work in this area with patients and referral sources. A few have decided that no training is necessary and have moved forward without an understanding of the complexity of the process. They lack even a basic awareness of the standards, tenets, methodologies or principles involved. Even many that have been involved in Life Care Planning for a number of years have failed to keep up with the changing process. The steps in establishing the needed foundations are an integral part of this process and without learning and following these steps, these individual Life Care Planners threaten the integrity of the entire sub-specialty. Life Care Planning is constantly being reviewed and judged by the referral sources and the State, as well as the Federal, Courts. This review is largely directed to the individual Planner for admission as an expert. Nevertheless, the courts are also looking at Life Care Planning as a secondary factor each time they look at the planner, and it is critical to all of the practitioners that each individual represent this sub-specialty well. No less critical to this process is the role of on-going research. Although it is not expected that each Life Care Planner be involved in research it is hoped that everyone understand the critical importance it plays in the current development of this sub-specialty. When given the opportunity, support of research in any way possible will be a factor in each person’s future practice.

About The Author

Paul M. Deutsch Ph.D., CRC, CCM, CLCP, FIALCP received a Master’s and Doctorate from the University of Florida and is President of the Foundation for Life Care Planning Research. He maintains a private practice in Rehabilitation Counseling and Mental Health Counseling and specializes in Life Care Planning. Dr. Deutsch is lead faculty at Kaplan University’s Life Care Planning program and teaches at the University of Florida/MediPro continuing education program in Life Care Planning. He has authored twelve texts and over 85 peer reviewed journal articles and chapters, including many on brain injury rehabilitation.

REFERENCES 1. 2. 3.

4. 5.

8. 9. 10.

11.

Core Curriculum Requirements for Life Care Planning, Commission on Health Care Certification, Standards and Examination Guidelines, (CDEC1), 2002. Core Curriculum Requirements for Case Management Certification, Certification for Case Manager, CIRS Commission, Rolling Meadows, IL. 1992. Deutsch, P.M., Kendall, S.L., Raffa, F., Danninhirsch, C., Cimino-Ferguson, S., Technologies impact on life care planning, Journal of Life Care Planning, pending publication Journal of Life Care Planning, Volume 4, Number 4, December 2005. Deutsch, Paul M.; Sawyer, Horace W.: A guide to rehabilitation, Volumes 1, 2 & 3. AHAB Press, White Plains, New York, 1995 with updates through 2005. Kendall, S.L., Casuto, D., A Quantitative reappraisal of a qualitative survey to assess reliability and validity of the life care planning process, Journal of Life Care Planning, Vol. 4, Number 2 & 3, 75-84, 2005. Marini, I., Harper, D., Empirical validation of medical equipment replacement values in life care plans, pending publication in Journal of Life Care Planning, Volume 4, Number 4, December 2005. Pomeranz, J.L., Personal assistance services for individuals with SCI: LCP practice implications. Pending publication in Journal of Life Care Planning, Volume 4, Number 4, December 2005. Scope of Practice for Life Care Planners, International Academy of Life Care Planners, 2000. Standards of Practice for Life Care Planners, International Academy of Life Care Planners, 2000. Sutton, A., Deutsch, P.M., Weed, R.O., Berens, D.E., Reliability of life care plans: A comparison of original and updated plans., Journal of Life Care Planning, Vol. 1. Number 3, pgs. 187-194, 2002. Weed, R.O., Case management and life care planning handbook. Boca Raton, Fl: St. Lucie/CRC, 2004.

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conferences 2006 JUNE 8-9 – 2006 Williamsburg Conference, Rehabilitation of the Adult and Child with Brain Injury: Practical Solutions to Real World Problems. Contact: (703) 451-8881, web: www.neuro.pmr.vcu.edu. 13-17 – CMSA’s 2006 Conference & Expo, Gaylord Texan Resort & Convention Center, Dallas/Ft. Worth, TX. Contact: (501) 225-2229, e-mail: cmsa@cmsa.org, web: www.cmsa.org. 16-19 – Festival of International Conferences on Disability, Aging and Technology: Advances in Neurorehabilitation, Toronto, Ontario. Contact: e-mail: info@ abinetwork.ca, www.abinetwork.ca. SEPTEMBER 14-16 – 19th Annual Conference on Medical and Legal Issues in Brain Injury. Eden Roc Resort, Miami, FL. Contact: conference@nabis.org, web: www.nabis.org. 14-16 – NABIS Brain Injury Conference of the Americas at the Eden Roc Resort, Miami, FL. Contact: conference@nabis.org, web: www.nabis.org. OCTOBER 25-28 – 26th Annual Conference of the National Academy of Neuropsychology, Marriott San Antonio Rivercenter, San Antonio, TX. Contact: (303) 691-3694, email: office@nanonline.org, web: www.nanonline.org. NOVEMBER 3-5 – 4th Annual Pediatric Brain Injury Conference. Miami, Florida. Sponsored by the University of Miami Miller School of Medicine. Visit: www.pedibrain.org. 5-6 – 26th Annual Neurorehabilitation Conference on TBI, Stroke and Other Disorders, Braintree, MA. Contact: (781) 348-2113, e-mail: donna.carr@healthsouth.com.

2007 FEBRUARY 15-17 – Pacific Coast Brain Injury Conference in partnership with the Brain Injury Association of Canada presents Canada’s National Brain Injury Conference. Hyatt Regency, Vancouver, BC, Canada. Contact: (604) 949-0716, www.pcbic.org. JUNE 10-14 – 4th World Congress of the International Society of Physical Medicine and Rehabilitation, Seoul, Korea. Contact: isprm2007@intercom.co.kr, www. isprm2007.org. 16-19 – Advances in Neurorehabilitation: Part of The Festival of International Conferences on Caregiving, Disability, Aging and Technology (FICCDAT), Toronto, Canada. Contact: catherine@smartmove.ca, www. ficdat.ca. 17-21 – International Brain Injury Association’s Seventh World Congress on Brain Injury, Jerusalem. Contact: www.kenes.com/ibia07. 22-24 – Joint Meeting of WFNR and EMN, Fiuggi, Italy. Contact: fservade@ausl-cesena.emr.it, www. emn.cc. SEPTEMBER 24-27 – 5th World Congress for NeuroRehabilitation, Rio de Janeiro, Brazil. Contact: traceymole@wfnr. co.uk. 16 BRAIN INJURY PROFESSIONAL

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Putting Lives In Motion for 21 Years

BRAIN INJURY PROFESSIONAL

Life Care Planning for the Client with a Brain Injury

by Susan Riddick-Grisham, BA, RN, CCM, CLCP and Robert H. Taylor M.A., L.P.C., C.R.C., C.D.M.S., C.L.C.P. as a roadmap to the future, which in many cases will include ongoing Introduction Approximately 1.5 million Americans sustain a traumatic brain injury medical and therapeutic interventions, equipment needs, and lifelong (TBI) each year, with an estimated 80,000 to 90,000 of those injured support services. The purpose of this article is to provide an overview of the methodexperiencing a long-term disability (Thurman et al., 1999). The lives of these individuals and their family members can change profoundly as a ology used by trained and knowledgeable life care planners. The authors result. The array of problems experienced by a person following a brain will also discuss a few of the many complexities faced by life care planinjury can be boundless and affect almost every bodily function. Even ning professionals who create plans for individuals with brain injuries. some subtle problems associated with a brain injury can have a dramatic impact on an individual’s ability to work or live independently. Life Care Planning Methodology Imagine how someone with a major sleep disorder secondary to a A life care plan is defined as: brain injury will function in her role as mother and caretaker to three A dynamic document based upon published standards of practice, comyoung children, all of whom need to be transported to soccer games, prehensive assessment, data analysis and research, which provides an orgatutored in their school work and watched over to ensure they are safe. nized concise plan for current and future needs with associated costs for indiOr consider the child who sustains a brain injury that causes hyperactiv- viduals who have experienced catastrophic injury or have chronic healthcare ity and a learning disability, and the needs he will have as he grows and needs. (IALCP, 2005) develops, attends school, looks for a job and settles into his adult years? The field has developed and published standards of practice for life While one would hope to be able to find clear-cut and simple solutions to care planning which outline the philosophy, goals, role and functions of the biological, psychological and social problems associated with a brain life care planning, and delineate standards of performance as defined by injury anticipating the future needs can be a formidable challenge. life care planning professionals. A major part of the life care planning Development of a plan of care for individuals with complex medi- methodology involves the use of a reliable system for the accumulation cal needs has always been an integral part of the medical and rehabilita- and documentation of information. Applying this consistent and objection process. Acknowledging the need for an organized approach to the tive methodology reduces the likelihood of error and omissions (Ridanalysis of lifelong needs, Drs. Paul M. Deutsch and Horace Sawyer in- dick-Grisham, 2004). troduced the concept of life care planning as a process for development At the time of referral, the life care planner will require all medical reof a comprehensive plan which delineates the costs of the resources cords including any notes obtained from the scene of an accident includneeded to meet the individualized needs of the client. In today’s increasing EMT or emergency transport records, physician and therapy notes, ingly complex health care climate, life care planning is a methodology consults, lab studies, and home health care records. It is not unusual for that considers the individual with the injury and the impact of the dis- the life care planner to request pre-injury/pre-illness records to allow for ability, the clinical team and service providers, the individual’s family, the identification of pre-existing conditions which could impact on the and takes into account the changes in needs that will occur over time as individual’s future medical or psychosocial needs (Table 1). the individual ages (Riddick-Grisham, 2004). In pediatric cases, the life care planner will want to view all school Life care plans (LCPs) are develrecords including Early Intervention A sample case overview with life care planning charts can records and Individualized Educaoped for use in a variety of settings. In civil litigation, life care planning tion Plans (IEPs) and standardized be downloaded from www.nabis.org/bip experts are frequently consulted retesting. Life care planners who are garding the life care needs of the individual who has been injured and asked to render vocational opinions may request additional materials the related lifetime costs. Rehabilitation and case management profes- such as the school and employment records, tax returns and information sionals use life care plans to create an integrated continuum that can regarding academic levels of achievement and work history. Employimprove outcomes, reduce complications, and ensure the appropriate ment records can provide valuable information regarding skills acquired use of resources for persons with chronic illness or catastrophic injuries. on jobs and the functional exertional demands of past employment. Patients and their families and other caregivers use the life care plan Medical bills are frequently reviewed by life care planners to track 18 BRAIN INJURY PROFESSIONAL

usual and customary care. The bills can also provide historical documentation of the frequency of disability related complication and the associated costs. This information is useful when forecasting the future need for similar care. Personal log books, diaries and videotapes compiled by the client and family can provide the life care planner with valuable insights into the day-to-day demands of caring for the individual who has been injured. This can also provide insight into the challenges faced by the individual on a daily basis. The life care planner will want to review all depositions of the treatment providers, employers, family members, school personnel and any experts who are expected to offer opinions regarding the client’s disability and future needs. If the referral involves a case which is in litigation it is also helpful to provide the life care planner with a comprehensive list of all other experts who are expected to offer opinions regarding future medical or psychosocial needs and life expectancy. One of the most important steps in the life care planning process is the interview with the individual and his or her family. There are many cases involving litigation where in-person interviews may not be possible due to factors that are beyond the control of the life care planner. Whenever possible, it is best to conduct the interview in the setting where the individual is residing. Valuable information can be obtained by viewing the home for accessibility and safety issues. Observation of family dynamics can also offer insight into issues such as the need for caregiver education or problems associated with caregiver burnout. During the interview session the life care planner will want to examine all medical equipment, develop a comprehensive listing of all medications and supplies being utilized by the individual and interview the client as well as many of the family members, if available. In some instances the family will be interviewed separate from the client to allow for candid discussion of limitations in function, behavioral issues and other sensitive information. The next step in the completion of the life care plan involves collaboration with the clinical, therapy, and at times, school teams and other community providers including home health. According to Weed (2004), “a qualified life care planner must be a collaborator, participant, and author of the life care plan.” When possible, the life care planner will consult with members of the clinical team to gather their opinions regarding the individual’s future needs (Table 2). Soliciting input from team members and drawing from their unique training and experience allows for development of a care plan that is based on medical and rehabilitative probability and focuses on achievement of durable long-term outcomes. Most life care planners are not physicians and in order to create the medical foundation or rationale for medically related items in the plan, it is essential that the planner establish a collaborative model which includes other clinicians as well as the application of relevant established protocols as outlined in published Clinical Practice Guidelines. During the initial phase of the work up, it not uncommon for the life care planner to identify areas that require additional exploration, prior to the completion of the LCP. The process of “filling in the holes” can include requests for updated neuropsychological or psychological evaluations, behavioral assessments or something a simple as a follow up visit with the physiatrist to document up to date problems and treatments. The following categories are considered in the development of each life care plan. Even though all of these categories should be evaluated, which of them will apply or be necessary for the formulation of an effective life care plan will depend on the diagnosis and other criteria in each individual case. As Deutsch notes in the basic Tenets of Life Care Planning, “the costs provided in the life care plan do not include two important categories: potential complication and future technology. The costs associated with these areas cannot accurately be predicted.” • Projected Evaluations • Projected Therapeutic Modalities • Diagnostic Testing/Educational Assessment • Wheelchair Needs • Wheelchair Accessories and Maintenance • Aids for Independent Functioning • Orthotics/Prosthetics

Step-by-Step Procedure for Life Care Planning

Table 1 CASE INTAKE

When you talked with the referral source, did you record the basic referral information? Time frames discussed? Financial/billing agreement? Retainer received (if appropriate)? Arrange for information release?

MEDICAL RECORDS

Did you request a complete copy of the medical records? Nurses notes? Doctors orders? Ambulance report? Emergency room records? consultants reports? Admission and discharge reports? Lab/x-ray/etc.? Are there depositions of the client, family or treatment team that may be useful? “Day in the life of ..” video tapes? And if vocational issues to be included in report - School records (including test scores)? Vocational and employment records? Tax returns? Is the interview to be held at the client’s residence? Have you arranged for all appropriate people to attend the initial interview (spouse, parents, siblings)? Did you allow 3 to 5 hours for the initial interview? Do you have the initial interview form for each topic to be covered? Supplemental form for pediatric cases, CP, TBI, SCI as needed? Do you have a copy of the life care plan checklist? Example plan to show the client? Copy of appropriate Life Care Plan step-by-step booklet? Camera or video camcorder to record living situation, medications, supplies, equipment, and other documentation useful for developing a plan?

SUPPORTING DOCUMENTATION INITIAL INTERVIEW ARRANGEMENTS

INITIAL INTERVIEW MATERIALS

CONSULTING WITH THERAPEUTIC TEAM MEMBERS PREPARING PRELIMINARY LIFE CARE PLAN OPINIONS FILLING IN THE HOLES RESEARCHING COSTS AND SOURCES FINALIZING THE LIFE CARE PLAN LAST BUT NOT LEAST

Have you consulted with and solicited treatment recommendations from appropriate therapeutic team members? If you do not have access to treating professionals, do you have adequate medical foundation for opinions (from records or consulting MD)? Do you have information which can be used to project future care costs? Frequency of service or treatment? Duration? Base cost? Source of information? Vendors? Do you need additional medical or other evaluations to complete the plan? Have you obtained the approval to retain services of additional sources from the referral source? Have you composed a letter outlining the “right” questions to assure you are soliciting the needed information? Have you contacted local sources for costs of treatment, medications, supplies, equipment? Or do you have catalogs or flyers? For children, are there services that might be covered, in part, through the school system? Did you confirm your projections with the client and/or family? Treatment team members? Can the economist project the costs based on the plan? Do you need to coordinate with a vocational expert? Do you need to determine life expectancy (opinion from MD or someone uniquely qualified). If “normal” what tables should be used? Have you distributed the plan to all appropriate parties, (client, referral source, attorney, economist, if there is one)?

Collaborative Model for Life Care Planning

Table 2

Family Patient

Physical Team

Medical Equipment Provider

Home Health Life Care Planner

Therapy Team

Counselor

Case Manager

Pharmacy School

• • • • • • • • • •

Home Furnishings and Accessories Drug/Supply Needs Home Care/Facility Care Future Medical Care – Routine Transportation Health and Strength Maintenance Architectural Renovations Future Medical Care/Surgical Intervention or Aggressive Treatment Orthopedic Equipment Needs Vocational/Educational Plan

The life care planner must assess the duration and frequency of each need within all applicable categories and then assess the cost. Life care planning is multidimensional and when considering each recommendaBRAIN INJURY PROFESSIONAL

tion the life care planner must be cognizant of the potential effect it may have on other areas of the plan. For example, consider the client who is taking Dilantin for management of a seizure disorder. The life care planner must recognize and consider the high incidence of dental complications including overgrowth, reddening, and bleeding which are related to the use of this medication by including regular dental examinations to monitor for this probable complication. Or consider the child with ADHD with a learning disorder. Recognizing that medications are frequently used to manage the effects of ADHD the life care planner will consider what likely medications will be utilized in the future. This will probably require consultation with a medical doctor who is familiar with these medications and their clinical application. The life care planner will also consider the use of an aide in school or individualized tutorial services as well as other educational supports to enhance the child’s ability to participate in the public school system to the extent that their disability will allow. Although report formats vary from life care planner to life care planner, each format should clearly document the need for and cost of each given item, the expected duration of that need, and the projected frequency and cost of the item’s replacement. It is generally accepted that the life care planner will base cost assessments on the costs in the geographic location where the individual and family reside, and that obtaining several quotes allows the life care planner to demonstrate average costs or a cost range (Riddick-Grisham, 2004). To determine the lifetime total of the LCP the planner will need to identify the individual’s anticipated life expectancy. Unless the life care planner is a medical doctor they should not be expected to make such a determination of any reduced life expectancy, but instead should rely on the opinions of a life expectancy expert. Once the life care plan is completed, it is provided to the referral source, and whenever possible, reviewed with the family. For cases involved in litigation, certain rules apply regarding the disclosure of information. The life care planner should always consult with the referral source prior to disseminating and communicating the plan recommendations to others. Challenges Faced by Life Care Planners This section will address a few of the unique challenges faced by life care planners who prepare LCPs for clients with brain injuries. Such challenges include working with medical teams who do not have specific training and experience in treating brain injuries, and the complexities of dealing with the emotions and other factors related to litigation and addressing the validation of the “invisible” injury. Dealing with clinical providers who lack specialized knowledge The life care planner has a specific role of accurately establishing the future care needs of a survivor of a brain injury. Using their specialized knowledge and training, and combining it with that of an experienced clinical team, results in life care plans that are based on current treatment protocols and evidenced-based clinical guidelines in brain injury and research. To accurately project the medical, cognitive, behavioral and social needs of an individual with a brain injury, life care planners will want to consult with clinical teams with extensive experience in the management of brain-injured client. Unfortunately, it is not uncommon to see situations where a client is being followed by clinicians who lack this type of specialized knowledge. It is the life care planner who frequently assists in the referral of the client to one of the TBI Model Systems programs or other local resources for a comprehensive evaluation. Managing the impact of litigation When a traumatic brain injury is acquired and causation is deemed the result of negligence by another party, ensuing litigation can significantly impact not only the orientation of the life care plan, but whether the life care plan is ever implemented. The most difficult aspect of litigation is often the time that it takes to bring a case to resolution, and in many cases, receive funds necessary for treatment. Even at the end of trial, the delivery of funds is not assured. If the case is appealed after trial, many more years can go by without any resolution of the case. If group medical insurance is not available to the individual with the brain injury, and 20 BRAIN INJURY PROFESSIONAL

the attorney has not been able to persuade providers to deliver services on a lien basis, necessary medical treatment may be delayed or simply not provided, resulting in the failure of the individual to reach his or her maximum level of functioning. In addition, the individual who incurred the brain injury and his or her family may, unconsciously or otherwise, seek to exaggerate the extent of disability in order to maximize the potential monetary award in the ongoing or pending litigation and “punish” the individual responsible for causing the injury. Such thinking, whether conscious or not, sadly often detracts from the ability of the individual and family to get the most out of the recovery process. Other issues the life care planner may face when developing a life care plan as part of a litigation process include: • the anger and other volatile emotions the individual and family may exhibit; • the stresses and demands that documentation, depositions, and the trial put on the individual and family; • attorneys who are not familiar with the consequences of acquired brain injury and whose so-called expert witnesses perform biased evaluations and use outdated, inappropriate methodologies and standards of measurement; and • the possibility of an iatrogenic brain injury where, through interaction with medical experts as part of the litigation process, the individual grows convinced that his or her brain injury is more severe than it actually is and becomes less amenable to actively participating in therapy as a result. Validation of the “Invisible” Disability Brain injury survivors are frequently referred to as the “walking wounded”. They may appear physically recovered, but problems often surface as they try to return to school, work or independent living. Unless physical disability is visible, such as would be the case due to alterations in gait or through facial disfigurement, there can be little understanding of the significance of a brain injury. Disruption in cognition and emotional functioning may not be understood since these deficits cannot be seen. Family members, acquaintances and employers may not understand the individual’s inability to understand previously performed work tasks, household routines and changes in personality and behavior. Family members and the individual may not be able to explain sudden changes in behavior and cognition. There may be the resultant lack of understanding of the significance of the injury and recognition and acceptance of ongoing deficits. Family members endure significant longterm disruption and adversity after a brain injury (Kreutzer et al., 1992). When developing a lifelong plan of care the life care planner will identify various options aimed at ensuring stability of the individual’s social support network in a setting that encourages maximum independence and participation in the community. Issues of caregiver burnout, marital and family stressors, quality of life and safety are considered and supports. Support services can be provided by a number of different disciplines such as family and individual counseling, life skills coaching, vocational rehabilitation services to assist with transition to work and possibly job coaching to maximize the chances of successful return to work. But what about the services that address safety in the home?. It is easy to agree that someone with a physical deficit such as a spinal cord injury should be provided with either home health attendant or nursing services to assist them with completion of their activities of daily living requirements. But what about the individual who can independently complete their bathing and dressing but who is unsafe around the stove or needs help creating a grocery list? The idea of paying someone to live in the home for the sole purpose of providing safety supervision as opposed to hands on care is a foreign concept to some. Identifying the resources to meet this type of need can be a challenge for the life care planner. If the goal is to keep the individual in a home within their community the care planner might consider some simple technological solutions to secure the environment such as removing knobs from the stove, or installing an automatic shutoff switch to reduce cooking related problems. However, in many instances additional supports are required. Creative options must be considered by the life care planner when

assessing home care needs. Paid roommates, live-in or live near supports and paid family care giving are options that are often considered. Homemaker support services needed to maintain a clean, sanitary and safe environment in the home are also frequently considered. All home care supports are designed to facilitate independence and promote community integration, improve quality of life and reduce safety risks. Rehabilitation strategies included in the LCP should strive to assist the individual to be as independent as possible given the extent of the disability. These strategies will include more traditional therapies, medical interventions and technology. Creativity is paramount to the success of a LCP given the fact that no two individuals with brain injury have the same capabilities and limitations. While replacement services such as those provided by hands-on caregivers may be necessary in some cases, their involvement should never be included in a LCP as a “mandatory” need. The role of human capital to replace the individual’s ability to perform activities of daily living must be assessed on a case-by-case basis. Summary The Life Care Plan can provide a lifelong guide for the delivery of health care and related services for the individual with a brain injury. The methodology employed by professional life care planners involves collecting information through records review, interviews, and observation; collaboration with an interdisciplinary team of health care providers; and documentation of the needs of the individual over time and the related costs. The standards of practice adhered to by professional life care planners and awareness of the specific challenges encountered in developing life care plans for individuals with acquired brain injuries can help ensure that the plan is an accurate and complete document that provides for their future care needs arising from their disability.

About the Authors

Robert H. Taylor M.A., L.P.C., C.R.C.,C.D.M.S.,C.L.C.P. is President and director of Vocational Diagnostics, Inc. in Phoenix, AZ. Mr. Taylor earned a Master’s degree in Rehabilitation Counseling from New York University in 1975. He is a licensed professional counselor by the Arizona Board of Behavioral Health Examiners. He holds certifications as a rehabilitation counselor, disability management specialist and life care planner. Mr. Taylor is President of the International Association of Rehabilitation Professionals (IARP). Mr. Taylor is a frequent speaker regarding life care planning and the evaluation of individuals, particularly children, who have had traumatic brain or spinal cord injuries. Mr. Taylor’s practice is national in scope and primarily involves catastrophic injury cases. He is privileged to have been asked by attorneys representing survivors of the September 11 tragedy at the World Trade Center in New York to develop life care plans for submission to the Victim Compensation Fund. Susan Riddick-Grisham has greater than 25 years of experience working with patients, families and clinical teams. Known for her skills as a catastrophic injury nurse case manager, Susan is also a nationally respected figure in the Life Care Planning community. In 1992 she participated in the development of the first comprehensive national training program for life care planners. Her passion for assisting individuals with chronic disabling health conditions continues to drive the development of innovative educational programs. These programs enable Susan’s colleagues to better serve their clients and families. In addition, Susan is a frequently requested life care planner, consultant, speaker, author, and mentor. Susan is the Founder of The Care Planner Network, an online community which is dedicated to improving the reliability and validity of the life care planning process by narrowing the variance in practice patterns, and by providing resources and networking opportunities to all practicing life care planners. She is also President of Life Care Manager, LLC which provides care manager and life care planning services on a national level.

References

Deutsch PM, Allison L., and Reid C.: An introduction to life care planning history, tenets, methodologies and principles. In: A Guide to Rehabilitation, (White Plains: AHAB Press, 2003. International Academy of Life Care Planners, Standards of practice. Retrieved September10, 2005 from http://www.ialcp.com/life_care_planning_guidelines.html#intro. Kreutzer JS. Marwitz JH. Kepler K. (1992) Traumatic brain injury: family response and outcome. In: Archives of Physical Medicine and Rehabilitation.73(8):771-8, 1992. Riddick-Grisham S. (Ed.). The role of the life care planner in pediatric life care planning. In: Pediatric Life Care Planning and Case Management, St. Lucie/CRC Press, LLC. Boca Raton, FL: page 49, 2004. Riddick-Grisham S. (Ed.). The role of the life care planner in pediatric life care planning. In: Pediatric Life Care Planning and Case Management, St. Lucie/CRC Press, LLC. Boca Raton, FL: page 52, 2004. Riddick-Grisham S. (Ed.). The role of the life care planner in pediatric life care planning. In: Pediatric Life Care Planning and Case Management, St. Lucie/CRC Press, LLC. Boca Raton, FL: page 60, 2004. Thurman DJ. Alverson C. and Dunn KA. , et al., Traumatic brain injury in the United States: A public health perspective. Journal of Head Trauma Rehabilitation. 14(6): 602-615, 1999. Weed R. :(Ed.). Life Care Planning and Case Management Handbook (2nd ed.), St. Lucie/CRC Press, LLC. Boca Raton, FL: 2004.

professional appointments Speech-Language Pathologist Clinician needed in Galveston, TX to assess and treat speech, swallowing, and cognitive-linguistic deficits of adults with brain injury. Masters Degree, CCC and Texas license or eligibility for same. Will consider Clinical Fellow. If qualified send resume or call: Cynthia Calhoun, PHR, Director Human Resources, Transitional Learning Center, 1528 Postoffice Street, Galveston, TX 77550, (409) 797-1445, Fax: (409) 797-1480, or e-mail: ccalhoun@ tlc-galveston.org EOE. RN Clinical Educator for brain injury, spinal cord injury and stroke patients. Touro Infirmary, New Orleans, LA. Minimum 5 years experience. BSN required. MSN preferred. Apply online at www.touro.com Physical Therapist, Physical Therapy Assistant, Speech & Language Pathologist openings at Craig Hospital. For information go to www. craighospital.org Career Opportunities, Current Employment Opportunities, or send resume to Susi Szaltzer, RN, BSN, MS, Healthcare Recruiter, Human Resources, Craig Hospital, 3425 South Clarkson Street, Englewood, CO 80113. Phone: (303) 789-8463, Fax: (303) 789-8684 or Sszaltzer@craighospital.org Program Director - Brain Injury and Pediatrics. Brooks is a 143 bed non-profit rehab hospital facility. We are moving towards a “program focus”, and are looking for clinical professionals to help us on this journey to excellence. Responsible for the delivery of quality care to patients, the development of new business and the monitoring of the bottom-line financial performance results. You must strike a balance between the day to day operations issues and strategic development initiatives to position the hospital for solid, long-term growth. Through collaboration with the Medical Directors for the programs the candidate will control the management and delivery of their particular product line. Supervision of PTs, OTs, SLP, Nurses, Psychologists and administrative personnel. (BSNs or BS Therapists are encouraged to apply.) Contact Liz Figura at (904) 858-7302, Fax (904) 858-7386, elizabeth. figura@brookshealth.org or mail to: Brooks Rehabilitation, Attn: Liz Figura, 3901 University Blvd. South, Jackonsville 32216. RNs Touro Rehabilitation Center is seeking RNs full time, part time, and flex for their 27 bed Physical Rehab Unit for Stroke and SCI patients who need bedside rehab nursing caregivers. Prefer Certified Rehabilitation Registered Nurses, 8 and 12 hour shifts, with weekend-only options available. Competitive salary. Contact Susan Greco at GrecoS@Touro.com or phone (504) 897-8082 to apply. CNAs, Rehab Assistants & PC Techs Touro Rehabilitation Center is seeking CNAs, Rehab Assistants, and Patient. Care Techs for overnight 8-hour shifts, with weekend-only options available. New competitive salary ranges and differentials. Contact Susan Greco at (504) 897-8082 or by email, GrecoS@Touro.com to apply. Staff OTs Touro Rehab Center is seeking staff OTs for inpatient and outpatient programs. Experience preferred. To apply, contact Marylee Pontillas at (504) 8978309 or by email at PontillasM@Touro.com Residential Treatment Coordinator Centre for Neuro Skills in Irving, Texas, has a position for a Residential Treatment Coordinator. This position involves writing and overseeing treatment programs for our residential rehab clients. Excellent benefit package, license/CEU, paid time off! Come join our team! Call (972) 580-8500 for more info! Send resumes to: Att: HR, e-mail: hrts@neuroskills. com, fax: (972) 255-3162, Centre for Neuro Skills, 1320 W. Walnut Hill Lane, Irving, TX 75038 Nurses needed for brain injury rehab at Centre for Neuro Skills, a post-acute brain injury rehab clinic which offers intensive residential and out-pt rehab for clients recovering from all types of acquired brain injury. The CNS community based approach focuses on helping clients regain a normal rhythm of living. Irving, TX clinic has openings for Licensed Nurses, M-F, holidays off, exc. benefits. Rehab experience is preferred. Resumes to hrtx@neuroskills.com or call (972) 580-8500. Physical Therapists Touro Rehabilitation Center is seeking staff PT’s for their CARF accredited SCI and general medical rehab programs. PTs with experience in SCI and general rehab preferred. To apply, contact Barbara Adcock at (504) 8978310 or by email at AdcockB@Touro.com To list your professional appointments on this page, please contact Joyce Parker, (713) 526-6900, or by e-mail: jparker@hdipub.com. BRAIN INJURY PROFESSIONAL

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Certification and Training in Life Care Planning by Lori A. Allison, MA, CLCP, MSCC and Paul M. Deutsch PhD, crc Introduction

accountability and protection for consumers who are the recipients of life Life care planning is a specialty area of practice that has evolved since its care planning services. Further, certification obligates professionals to abide introduction into the professional literature in 1981. With the publica- by the established code of ethics and to practice within the standards action of the multi-volume text, Damages in Tort Actions, authors Paul M. cepted within the specialty. Violations of such standards may result in reDeutsch and Fredrick A. Raffa described the basic tenets and methodolo- vocation of certification credentials and other disciplinary actions (May and gies applied to catastrophic injury case analysis (Deutsch and Raffa, 1981). Lubinskas, 2004). Life care planners approach the planning process with This text was followed by the publication of A Guide to Rehabilitation in a collaborative orientation and rely upon recommendations of the entire 1985, which with subsequent annual updates remains a seminal reference for treatment team. The training and certification process prepares planners to life care planners, case managers, and rehabilitation professionals (Deutsch integrate research literature, clinical practice guidelines, and data obtained and Sawyer, 1985). After more than 20 from brain injury professionals to deyears, numerous publications have deAs the specialty of life care planning evolves over time, velop a plan that addresses the longscribed state-of-the-art practices in life training and certification organizations will continue to term needs of individuals across the care planning and the importance of of care. refine their programs, and consequently, to enhance the continuum advanced practice training. The purpose Currently, there are two organizacompetence and professionalism attained through adof this article is to describe the national tions that confer national board certicertifications and primary educational fication: the American Association of vanced study within this area of practice. programs available to professionals who Nurse Life Care Planners Certification are interested in pursuing advanced training in life care planning. Because Board (AANLCPCB) and the Commission on Health Care Certification successful service delivery relies upon effective collaboration among members (CHCC). While each of these groups has established its own set of certiof the interdisciplinary team, it is important for brain injury professionals to fication requirements (See Table 1), the Certified Nurse Life Care Planner understand this process in order to appreciate the knowledge base and skill (CNCLP) and Certified Life Care Planner (CLCP) credentials distinguish set required for certification in this specialty area of practice. professionals as having achieved an advanced level of training and competence in this specialty area of practice.

Certification

With its foundation in rehabilitation, life care planning attracts qualified health care professionals from diverse areas of practice, such as rehabilitation counseling, case management, rehabilitation nursing, psychology, physical therapy, vocational rehabilitation counseling, occupational therapy, and physiatry. In addition to achieving board certification or licensure within their primary disciplines, many professionals choose to pursue board certification in life care planning. May (2002) notes that certification provides a measure of professional 24 BRAIN INJURY PROFESSIONAL

American Association of Nurse Life Care Planners Certification Board The AANCLCPB was established as a division of the American Association of Nurse Life Care Planners (AANLCP) and maintains its autonomy as a certification body (AANLCP, 2005a). The first CNLCP credential was awarded in 1998 and since that time, more than 350 nurses have acquired this designation. The AANCLCPB is a member of the American Board of Nursing Specialties and is currently pursuing accreditation of the CNLCP

Certification

Table 1 American Association of Nurse Life Care Planners Certification Board

Commission on Heath Care Certification

Organizational Structure

Association members are elected by the membership to serve on the Board.

Qualified health care practitioners representing a range of disciplines are appointed as Commissioners

Credential Conferred

Certified Nurse Life Care Planner (CNCLP)

Certified Life Care Planner (CLCP)

More than 350

More than 700

Number of Credentials Conferred Year First Credential Awarded

1998

1996

Examination Format

Onsite examination

Certification Renewal

Every five years, 60 continuing education points, or re-examination

Examination Fee* Certification Information

Examinees may select onsite or online test administration Every three years, 48 clock hours of continuing education experience, or re-examination

$250

$445

www.aanlcp.org/certification_info.php

www.chcc1.com

*These examination fees were verified in July 2005 and are subject to change.

Table 2

Training Programs American Association of Nurse Life Care Planners

Participant Requirements

Registered nurses

Capitol University Law School

Kaplan University

University of Florida/ MediPro Seminars

Qualified healthcare professionals as identified by CHCC*

Program Format

Onsite in Salt Lake City, UT

Onsite in Columbus, OH and distance learning courses

Online

Onsite seminars in various locations and distance learning modules

Program Duration

Seven days

Eight months

Self-paced; average six to eight months

Three months for onsite sessions; self-paced distance learning modules

$3,000 for AANCLP members; $3,700 for non-members

$5,448

$3,350

Tuition begins at $2,800 for prepaid enrollment

Financial Aid/ Group Rate

Discounted accommodations rate for groups

Financial aid is available for qualified students

Flexible payment plans are available

Group rates available

Certification Organization

Association of Nurse Life Care Planners Certification Board (AANLCPCB)

Commission on Health Care Certification (CHCC)

Credential Conferred

Certified Nurse Life Care Planner (CNCLP)

Certified Life Care Planner (CLCP)

Program Information

www.aanlcp.org

www.law.capital. edu/LCP

www.kaplan.edu

www.mediproseminars.com

Program Cost**

*CHCC identifies a qualified healthcare professional as one who is actively involved in the care, treatment, and/or rehabilitation of individuals with significant disabilities such as: rehabilitation counselors, case managers, psychologists, or nurses. **These program costs were verified in July 2005 and are subject to change.

examination through this organization in order for nurse life care planning to be formally identified as a nursing specialty. Certification through AANCLPCB is restricted to registered nurses with a minimum of two years of case management or related experience. Additionally, candidates must have obtained a minimum of either 61 direct contact hours from an approved life care planning program or documentation of 500 hours of life care planning experience within the immediate two-year period (AANLCP, 2005a). The CNLCP examination is administered by the Professional Testing Corporation two times per year in various locations throughout the United States and requires a $250 administration fee. When an individual attains a passing score on the CNLCP examination, the credential is valid for a period of five years. Renewal of certification is accomplished through re-examination or submission of 60 points of credit (AANLCP, 2005a).

Commission on Health Care Certification (CHCC) The CHCC was originally established as the Commission on Disability Examiner Certification (CDEC) in 1994 and revised its name in 2002

to reflect the diversity of certifications that had evolved since its inception. The first CLCP credential was awarded by CHCC in 1996, and more than 700 professionals have subsequently earned this distinction. The CHCC is currently seeking accreditation through the National Commission on Certifying Agencies and has completed the second phase of this lengthy process (CHCC, 2005a). In addition to possessing primary certification in a qualified health-related field, eligibility requirements include a minimum of 120 hours of postgraduate or post-specialty degree training, successful completion of a peer-reviewed life care plan or one year of supervision with a CLCP, and attainment of a passing score on the certification examination. Candidates may take the certification examination at CHCC headquarters in Midlothian, VA or at various locations throughout the United States and must pay an administrative fee of $250. In 2005, CHCC provided candidates with an additional testing alternative by making the examination available in an online format. Documentation of 48 clock hours of continuing education is required every three years for renewal of certification (CHCC, 2005b).

Training There are four primary comprehensive training programs available to professionals interested in obtaining the requisite hours of post-graduate or postspecialty degree training toward certification in life care planning (See Table 2). These programs have been skillfully developed by experienced life care planners and are taught by recognized leaders within the specialty. Each program provides participants with a unique learning format, but all curriculums focus upon the essential elements of life care planning practice. Given the unique features of each organization, professionals who are interested in pursuing training within this specialty area are able to review the eligibility requirements and structure of each program and select the approach which is most compatible with personal learning preferences.

American Association of Nurse Life Care Planners The American Association of Nurse Life Care Planners (AANLCP) was established as an organization to support the needs and interests of registered nurses working in the specialty of life care planning (AANLCP, 2005a). This organization provides a comprehensive life care planning training program as well as continuing professional and educational opportunities for members. Since 1998, AANLCP has been a provider of requisite training toward certification. Participation in AANLCP’s life care planning program is reserved for registered nurses only. The AANCLP provides a seven-day onsite training program in Salt Lake City, Utah that includes the following courses (AANLCP, 2005b): • Life Care Planning and the Future: Explores the use of the nursing diagnosis, tools for life care planning, and starting a business. • Spinal Cord Injuries: Includes anatomy, complications, medical and therapy needs, equipment, and other issues relevant to plan development. • Traumatic Brain Injuries: Anatomy, complications, the neuropsychological evaluation, medical and therapy needs, and other essential concepts are discussed. • Burns: Presents the rehabilitation process, medical and therapy needs, equipment considerations, and related topics. • Chronic Pain: In addition to addressing the needs of individuals with chronic pain, this course provides instruction in critiquing a life care plan from the defense perspective. • Cerebral Palsy: Etiology and management, medical and therapeutic needs, equipment, resources, and other issues of relevance are explored. • Life Care Planning and the Law: Allows participants to consider issues related to expert testimony and the unique case analysis methodologies utilized by plaintiff and defense counselors. Program enrollment fees begin at $3,000 for members of AANLCP and $3,700 for non-members, and group discounts on hotel accommodations are available (AANLCP, 2005b). Upon completion of the training program, qualified participants may seek certification through the American Association of Nurse Life Care Planning Certification Board (AANLCPCB). BRAIN INJURY PROFESSIONAL

Capitol University Law School Capitol University Law School established its life care planner program in 2002 and is a track within the school’s paralegal/legal nurse consultant program. Participants attend eight monthly weekend onsite sessions in Columbus, OH, complete distance learning activities, and communicate via web-based discussion boards throughout the program. Admission is open to a range of professionals such as registered nurses, occupational health nurses, rehabilitation counselors, disability management specialists, vocational counselors, physical therapists, and others with licensure and/ or certification in health-related areas. Participants complete the following modules over the course of eight months (Capitol University Law School, 2005a): • Life Care Planning Methodology and the Assessment Process: Introduction to the life care planning process, including assessment, record review, cost analysis, report writing, and other components of plan development. • Civil Litigation and Substantive Law: Pretrial: Explores civil litigation, tort law, legal ethics and other topics relative to life care planning in litigated cases. • Medical Rehabilitation Team Process and Referral Sources: Identifies the roles of various members of the rehabilitation team, the legal team, and others involved in the collaborative process. • Medical Research and Writing: In addition to writing style, this course explores medical and legal research databases and other data sources that inform the development of a life care plan. • Vocational Rehabilitation, Economics, Damages, and Structured Settlements: This course addresses multiple topics including the economic analysis of a life care plan, classification of damages, and structured settlements. • Workers’ Compensation and Social Security: An overview of applicable laws and benefit programs is presented. • Capstone Course: Participants prepare and submit a life care plan report for review and critique. • Trial Practice and Catastrophic Cases: Allows participants to gain an understanding of the civil litigation process through active participation in a number of applied exercises. Tuition for the program is $5,448, and federal financial aid is available for individuals who qualify (Capitol University Law School, 2005b). Capitol University Law School is an approved provider of requisite training for life care planning certification through CHCC.

Kaplan University Kaplan University launched its life care planning certificate program in July 2003 as part of its Continuing and Professional Studies, Health Care Pathways Division. All coursework is presented online with interactive bulletin boards and an internal 26 BRAIN INJURY PROFESSIONAL

e-mail system for communicating with instructors and other participants. This online learning community is supported by traditional academic advising and technical support services. Each course in the program is self-paced and participants have access to course material 24 hours per day. Participation in Kaplan University’s program is open to nurses, rehabilitation and vocational counselors, case managers, physical and occupational therapists, and other professionals who meet CHCC’s certification eligibility requirements. While the program is self-paced, the majority of participants complete the following courses within six to eight months (Kaplan University, 2005): • Introduction to Life Care Planning: Provides an overview of the basic tenets and methodologies of the life care planning process. • Standards and Ethics for Life Care Planning: Explores the standards of practice and code of ethics which guide life care planning practice. • Medical and Psychological Aspects of Disability I: Spinal Cord Injuries, Amputations, and Burns: Explores the unique medical, psychological, and rehabilitation considerations involved in plan development. • Medical and Psychological Aspects of Disability II: Brain Injury and CVA/Stroke: In addition to the medical and rehabilitation needs of individuals with varying degrees of brain injury, this course discusses options for long-term management. • Medical Aspects of Disability III: Selected Conditions: This course discusses life care planning in cases involving sensory impairments, psychiatric disabilities, HIV/AIDS, chronic pain, and other conditions. • Using Research Literature and Clinical Practice Guidelines: Emphasizes the importance of evidence-based research foundations, interpretation of published research, and utilization of appropriate data resources. • Pediatric and Elder Care Management: Addresses the unique needs of pediatric and geriatric populations and discusses relevant laws, community agencies, and specialized support services that inform the development of the life care plan. • Special Needs Trusts and Medicare Set-Asides: Provides an overview of post-settlement options that maximize benefits while protecting long-term financial interests. • Development of the Life Care Plan: This is an optional course which provides guidance to participants who wish to complete the requisite peer-reviewed life care plan for submission to CHCC. The tuition fee for the program is $3,350 and flexible payment plans are available to qualified individuals (Kaplan University, 2005). Kaplan University is an approved provider of requisite training for certification through CHCC.

gram has been in existence since 1987 and consists of both distance learning and onsite training modules which are presented in various locations throughout the United States. Participants attend four onsite seminars and complete the four remaining required courses through guided homestudy modules. Participation in the University of Florida/MediPro Seminars program is open to rehabilitation, medical and vocational professionals, including rehabilitation counselors, registered nurses, certified registered rehabilitation nurses, psychologists, psychiatrists, physical therapists, occupational therapists, speech and language pathologists, and physicians. The four onsite seminars are typically offered within approximately three months of one another and are repeated throughout the calendar year. Because the distance learning modules are self-paced, motivated participants are able to complete the following courses within three to four months (University of Florida/MediPro Seminars, 2005a): • Tenets and Methodologies of Life Care Planning: Introduction to the guiding principles of life care planning. • Spinal Cord Injuries: Explores the medical, psychological, rehabilitation, and vocational needs of individuals with spinal cord injuries as relevant to the life care planning process. • Multiple Disabilities: This distance learning module explores various aspects of the life care planning process as applied to cases involving orthopedic injuries, chronic pain, amputations, and other conditions. • Traumatic Brain Injury and Pediatric Brain Damage: Medical, rehabilitation, psychological, vocational and other planning considerations are presented in this distance learning module. • Pulling It All Together: This course allows participants to actively engage in exercises involving testimony, the planning process, and current issues impacting this specialty area of practice. • Forensic Rehabilitation: Basic legal procedures and the role of the life care planner within the litigated environment are discussed. • Vocational Rehabilitation Issues: In this distance learning module, vocational considerations, relevant laws, and rehabilitation issues impacting individuals with varying disabilities are explored. • Life Care Plan Preparation: Participants prepare and submit a life care plan for peer-review and critique in this distance learning module. The tuition fee for the program begins at $2,800 for individuals who prepay for the entire program, and group discounts are available (University of Florida/MediPro Seminars, 2005b). The University of Florida/MediPro Seminars is an approved provider of requisite training for certification through CHCC.

Continuing Education University of Florida/MediPro Seminars The University of Florida/MediPro Seminars pro-

Continuing education is a critical component of professional development and is required in order

to renew both the CNLCP and the CLCP credentials. Expertise in life care planning for individuals with brain injury evolves over time and through direct casework experience. Certainly, adequate training regarding the unique long-term planning considerations of this population is imperative, but the ultimate responsibility for developing expertise and clinical proficiency rests with the professional. May (2002) emphasizes that the mere possession of a credential does not imply that the quality of service delivery will exceed that provided by a non-certified professional. Rather, certification identifies a professional as having achieved a minimum set of standards and as having made a commitment to uphold the ethical code and standard of practice as described by the regulatory agency. Certified life care planners are obligated to engage in advanced training events and to remain informed of current practices in medicine, rehabilitation, and case management that may impact planning for the future needs of individuals with brain injury. Opportunities for advanced practice training are offered by a number of organizations and include online, onsite and distance learning formats. The American Association of Nurse Life Care Planners Annual Educational Conference and the International Conference on Life Care Planning allow professionals to discuss issues of relevance, to gain knowledge regarding current medical and rehabilitation research, and to share experiences and insights with others from across the nation. These conferences are well-attended and provide continuing education credits that can be applied toward recertification. Educational sessions are typically comprised of a variety of topics that are of particular interest to professionals such as ethical practice, standards of care and clinical practice guidelines, research outcomes in life care planning and specific disability areas, deposition and testimony, legal considerations, and other topics that directly inform the life care planning process. In addition to conference attendance, life care planners may earn continuing education credits through such activities as giving presentations at professional meetings and regional conferences, serving on committees, writing test items for certification examinations, publishing articles or texts, and other professional development experiences that enhance knowledge and practice (AANLCP, 2005a; CHCC, 2005b). Certification in life care planning connotes a level of expertise that distinguishes professionals as having acquired advanced, specialized skills. Equally important, certification communicates a commitment to continuous professional development, to lifelong learning, and to staying current with trends affecting the knowledge base and practice of life care planning. The existing training programs competently prepare professionals for certification within this practice area and provide a variety of learning structures from which to select modalities most compatible with personal learning styles and preferences. As the specialty of life care planning evolves over time, training and certification organizations will continue to refine their programs, and consequently, to enhance the

competence and professionalism attained through advanced study within this area of practice.

About the AuthorS Ms. Allison is a board-certified life care planner who develops long-term care and rehabilitation plans for individuals with catastrophic injuries and chronic illnesses. She is on the faculty of the life care planning certificate and case management programs at Kaplan University and serves on the curriculum development team. Ms. Allison is also an online instructor for the life care planning certificate program, which prepares students for board certification. She has published in the areas of life care planning, case management, and research design and statistics. Ms. Allison received a bachelor’s degree in psychology from the College of Wooster, a master’s degree in special education from The Ohio State University, and is currently a doctoral candidate in rehabilitation services at that institution. Her dissertation study explores the reliability and validity of life care planning methodology for individuals with spinal cord injuries. Paul M. Deutsch Ph.D., CRC, CCM, CLCP, FIALCP received a Master’s and Doctorate from the University of Florida and is President of the Foundation for Life Care Planning Research. He maintains a private practice in Rehabilitation Counseling and Mental Health Counseling and specializes in Life Care Planning. Dr. Deutsch is lead faculty at Kaplan University’s Life Care Planning program and teaches at the University of Florida/MediPro continuing education program in Life Care Planning. He has authored twelve texts and over 85 peer reviewed journal articles and chapters, including many on brain injury rehabilitation.

References

American Association of Nurse Life Care Planners, Certification information. Retrieved June 22, 2005 from https://www.aanlcp. org/certification_info.php, 2005a. American Association of Nurse Life Care Planners, Course information. Retrieved June 22, 2005 from http://www.kelynco. com/course_info.html, 2005b. Capitol University Law School, Life care planner (LCP) courses & scheduling. Retrieved June 22, 2005 from www.law.capital. edu/LCP, 2005a. Capitol University Law School, Tuition & aid. Retrieved June 22, 2005 from http://www.law.capital.edu/LCP/Tuition.asp, 2005b. Commission on Health Care Certification, Accreditation letter of intent sent to NCAA. Retrieved June 22, 2005 from http:// www.chcc1.com/News&notespage.htm#NCCA, 2005a. Commission on Health Care Certification, Standards and examination guidelines. Retrieved June 22, 2005 from http://www. chcc1.com/CdecbookPDF.pdf, 2005b. Deutsch PM Raffa FA: Damages in Tort Actions. New York: Matthew Bender/Lexis Nexis, 1981. Deutsch PM Sawyer HW: A Guide to Rehabilitation. New York: Matthew Bender/White Plains, NY: Ahab Press, 1985. Kaplan University, Life care planning certificate. Retrieved June 22, 2005 from http://www.kaplan.edu/hcp/programs/lcpMain. aspx?ID=School&loc=0&MainTab=Program&Program ID=33 197&School=HealthCarePathways, 2005. May VR, Certification in life care planning service delivery. Topics in Spinal Cord Injury. 7(4): 88-98, 2002. May VR Lubinskas P: The commission on health care certification (CHCC): Credentialing in life care planning service delivery. In Life Care Planning and Case Management Handbook (2nd Ed.). R Weed (Ed.) CRC Press, Boca Raton, FL. Pages 761-789, 2004. University of Florida/MediPro Seminars, Program overview. Retrieved June 22, 2005 from: http://www.mediproseminars. com/overview.aspx?ProgramID={14bfc710-82a0-4039-812efbb641f37ed9, 2005a. University of Florida/MediPro Seminars, Life care planning certificate program (LCP). Retrieved June 22, 2005 from: http://www. mediproseminars.com/programs.aspx ProgramID={14bfc71082a0-4039-812e-fbb641f37ed9}, 2005b.

BRAIN INJURY PROFESSIONAL

Earning Capacity Analysis: Foundations, Concepts, and Issues

by Ann T. Neulicht, PhD, CRC, CLCP, CVE, CDMS, LPC, ABVE-D and Brian Preston, MS, CRC, CLCP, ABVE-D Love and work are the cornerstones of our humanness Sigmund Freud An individual’s job and choice of career has a pervasive influence on his or her life. A job not only provides monetary reward, identity, and a sense of personal worth but also determines to a great extent one’s pattern of living, e.g., how time is spent, who one’s friends are, where one resides, and the attitudes and values one adopts. One of the most common and devastating consequences of an acquired brain injury (ABI) is the inability to return to a pre-injury job or career path. When a brain injury case involves litigation, value must be placed on the damages a plaintiff has sustained. The most costly damages are often those associated with the loss of wages and earning capacity. A vocational expert provides opinions regarding an individual’s vocational potential and residual earning capacity, as well as recommendations regarding alternative employment options and the need for rehabilitative services to enhance residual employment opportunities. These opinions may be incorporated into a life care plan or result from a separate referral and report. The purpose of this article is to provide an overview of the vocational assessment process used by rehabilitation counselors, including factors to consider in selecting a vocational rehabilitation professional, discussion of the vocational expert’s role in litigation, as well as review of evaluation and outcome issues specific to brain injury, including loss of competitive edge. Who is qualified to provide a vocational expert opinion? A testifying expert must provide opinions that are relevant and based on a reliable foundation (Federal Rules of Evidence, 2004). Regardless of whether a state applies the “general acceptance standard” established in Frye v United States (1923) or the qualifying language resulting from Daubert v Merrill Dow Pharmaceuticals (1993), the use of specialized knowledge, skill, experience, training, and protocols to formulate an objective and defensible opinion is required. Further, a valid opinion combines quantitative and qualitative information triangulated from multiple sources (Barros-Bailey and Neulicht, 2005). Vocational expert testimony requires expertise in specific areas, including: • familiarity with the field of vocational rehabilitation; • knowledge of vocational, educational and psychological assessment procedures; 28 BRAIN INJURY PROFESSIONAL

• • • • • • • •

familiarity with standard occupational references; familiarity with the concept of transferable skills; knowledge of job analysis; ability to determine the potential for future employment based on transferable skills, capacity for work, and labor market; knowledge of wage and earnings data; experience with the rehabilitation planning processes; ability to serve as a consultant to other professionals involved in the rehabilitation process; and skill in presenting vocational information (Field and Weed, 2001).

While their specific professional backgrounds may vary (e.g., vocational evaluation, psychology, career counseling), rehabilitation counselors whose practice and expertise include the skills outlined above are often called upon in litigation to serve as vocational experts in addressing vocational potential and future wage earning capacity. Rehabilitation counseling is a profession that “assists individuals with disabilities in adapting to the environment, assists the environments in accommodating the needs of the individual, and works toward full participation of persons with disabilities in all aspects of society, especially work” (Szymanski, 1985). At the core of a vocational opinion is the underlying principle of rehabilitation as “an individualized holistic process that is comprehensive in scope and prescriptive in nature that serves to develop or restore capacity with a goal of functional independence” (Maki, 1986). Philosophical tenets that form the foundation for the current vocational rehabilitation service delivery systems include consumer choice, empowerment, informed consent, integration (not discrimination), as well as the right of an individual to contribute to society in a citizen capacity. Services are oriented toward the whole person with a criterion of ultimate function in a normal environment using residual assets (McMahon and Shaw, 1996). The qualified rehabilitation counselor is trained to engage in a systematic process when evaluating individuals with disabilities and providing services. This process includes assessing client needs, developing a plan to meet identified needs, and coordinating the provision of medical, rehabilitation and vocational services to facilitate the client’s achievement of his/her highest level of independence and/or productivity. Certification as a rehabilitation counselor and/or vocational expert provides assurance that an individual meets nationally accepted standards of quality. To

become certified, applicants must satisfy specific educational and employment requirements and pass a standardized examination. Professionals who are certified are required to adhere to a code of ethics and demonstrate continuing professional development at specified intervals for certification renewal. Certification often promotes ongoing role and function studies to validate professional practice. Advantages of certification also include the establishment of a professional identity; enhanced credibility with other health care providers, consumers, and the public; as well as increased professional marketability. The Commission on Rehabilitation Counselor Certification (CRCC) certifies rehabilitation counselors in the United States and Canada. Certified rehabilitation counselors (CRCs) must demonstrate, via a national examination, knowledge in the following areas: foundations of rehabilitation; client assessment; planning and service delivery; counseling and interviewing; and job development and placement. Many vocational experts are certified through the American Board of Vocational Experts (ABVE). ABVE certification signifies advanced specialty status as an expert or “opinion” witness and as an “impartial educator” who collects, evaluates and presents objective evidence for judicial purposes. For details regarding scope of practice and qualifications, as well as the process of certification and renewal, the reader is referred to CRCC (2005) and ABVE (2005). Not all rehabilitation counselors are vocational experts or have specialized experience/expertise in brain injury and sequelae. A relevant educational background with degrees from accredited institutions and specific experience working with individuals who have sustained an acquired brain injury are imperative. Other considerations include experience in case management, vocational assessment, job placement, and for pediatric cases, special education or early intervention. In addition, factors such as professional organization memberships, conference attendance, presentations, and publications help to indicate the professional base from which expert opinions are provided. Qualified vocational rehabilitation consultants/experts usually belong to a variety of professional associations (e.g., National Rehabilitation Counseling Association, American Rehabilitation Counseling Association, International Association of Rehabilitation Professionals). Many vocational rehabilitation consultants/experts also belong to organizations that focus on the concerns of those with specific disabilities (e.g., Brain Injury Association, National Spinal Cord Injury Association) and may hold other certifications (e.g., licensed professional counselor, certified vocational evaluator, certified case manager, certified disability management specialist, certified life care planner). The vocational expert’s role in litigation A vocational expert’s role in litigation is to assess the vocational handicaps (i.e., the restrictions that prevent the successful completion of an activity or task) that result from a disability, evaluate the transferable skills of the individual who has been injured, take into account the available labor market, and provide an opinion as to the individual’s capacity and opportunity to work (Neulicht and Costantini, 2002). Vocational experts must be knowledgeable about the parameters of the jurisdiction in which they are providing an opinion. For example, the return-to-work philosophy of the workers’ compensation and private rehabilitation sector is predicated on findings that the most effective method of achieving long-term vocational success is to return a worker who has been injured to his or her former job (Cheit, 1961). The hierarchy developed by Matkin (1981, 1982) and Welch (1979) has become a blueprint for return-to-work planning. Clients are more likely to be successful when they are faced with the smallest adjustment and placed in an environment that is as close as possible to what they experienced pre-injury. In this widely accepted paradigm, return-to-work options are evaluated in the following order: • same job, same employer; • modified job, same employer; • different job, same employer, using transferable skills; • same job, different employer, possibly including modifications; • different job, different employer, using transferable skills; • training for different job with same or different employer; and • self-employment. Case law may further define the parameters of a successful return to work. For example, in workers’ compensation, “make work” is generally not accepted as an outcome. The odd lot doctrine is defined as “any work that

the client may be able to perform which would be of limited quantity, dependability or quality and for which there is no reasonably stable market for their labor activities” (e.g., Gilcrease v. J.A. Jones Construction Co., 1982; Haynes v. State Accident Insurance Fund, 1976; Loprinzo v. Mald Corp., 1983; Spring v. Department of Labor and Industries of State of Washington, 1982). A vocational expert must also consider the client’s age, including issues involved in providing a vocational opinion for a child that has no work history (Neulicht and Berens, 2004) or the extent to which an older person is able to adapt to a new work situation and competitively perform job-related tasks (U.S. Department of Health and Human Services, 1981). Short-term or long-term disability cases typically require a determination of the client’s ability to perform his or her “own occupation” prior to consideration of “any occupation. In civil litigation, it is necessary to clarify the client’s vocational potential, including a determination of future vocational or educational needs as well as job modifications or specialized assistance (e.g., vocational counseling, supported employment, assistive technology). The vocational assessment process The qualified vocational expert follows a standardized process of information-gathering and decision-making to form an opinion about an individual’s capacity to work. Examples of case conceptualization models in the vocational psychology, rehabilitation counseling and case management literature are the Minnesota Theory of Work Adjustment (Dawis, England and Lofquist, 1964, 2005), Systemic, Ecological Model (Hershenson, 1998), INCOME (Beveridge et al., 2002) and RECAM or Rehabilitation Evaluation and Case Analysis Method (Sawyer, 2002). The RECAM process, for example, involves the following steps: case referral and acceptance, initial case review, client interview/ rehabilitation evaluation, case analysis/plan, case report/recommendations and case update. For further discussion of these models, see Neulicht and Berens (2005). In the forensic arena, Boyd and Toppino (1995) published a 12-step model to guide the vocational expert’s approach to wage loss analysis. The model includes consistent evaluation of the following elements: medical and/or psychiatric reports/diagnoses; medical restrictions, functional capacities; formal educational level; current level of aptitudinal function; employment history; age; prior specific vocational preparation; transferable skills assessment (TSA); labor market access; and wage rate data. A vocational diagnostic interview should be conducted when possible (an option that may not be available for vocational experts retained by defense attorneys). The RAPEL model is a widely accepted and recognized format for summarizing future care needs and earnings capacity opinions (Weed, 1993; Weed, 1995; Weed, 2000; Weed and Field, 2001; Weed, 2004). RAPEL is an acronymn which specifies consideration of the following elements: Rehabilitation plan to determine future medical care/life care planning needs; Access to the labor market; Placeability and employability factors; Earnings capacity analysis; and Labor force participation. PEEDS-RAPEL, illustrated in Figure 1, is a model for pediatric cases and expands the RAPEL approach. The PEEDS portion of PEEDS-RAPEL analyzes relevant data specific to the child, including (as per its acronym): Parental/ family occupations; Educational attainment; Evaluation results; Developmental stage; and Synthesis (Neulicht and Berens, 2005). In general, the steps involved in completing a forensic vocational assessment include a record review, interview, testing (as needed), gathering additional information, transferable skills analysis for individuals with work experience who have acquired a disability that precludes a return to work in the pre-injury occupation, and labor market research. Information is then analysed to provide an opinion on lost wages and/or earning capacity (Neulict and Costantini, 2002). Issues to consider in each of these stages are listed in Table 1. Lost wages refers to a dollar figure derived from the client’s actual work history to estimate the amount of money lost as a result of the disability, whereas lost earning capacity is an opinion regarding the loss of future earnings and is based on a reasonable estimation of the client’s work potential or capacity. In pediatric cases, lost earning capacity must take into account the family pattern of education/work and the likely pre- and post-incident options that are, within reasonable probability, available to a child (Neulicht and Berens, 2004). In many cases, it is necessary to go beyond determining whether the client is employable. Employability refers to a person’s ability to perform a particular occupation. It is determined by matching abilities and skills as they relate to BRAIN INJURY PROFESSIONAL

figure 1

table 1

PLACEABILITY

This represents the likelihood that the client could be successfully placed in a job. This is where the “rubber meets the road.” Consider the employment statistics for people with disabilities, employment data for the specific medical condition (if available), economic situation of the community and availability (not just existence) of jobs in chosen occupations. Note that, where appropriate, the client’s or family’s attitude, personality, and other factors will influence the ultimate outcome.

EARNINGS CAPACITY

Based on the above, what is the pre-incident capacity to earn compared to the post-incident capacity to earn? Consider categories and examples of occupations (e.g., unskilled, semiskilled, or skilled as a result of elementary/middle school, high school, technical school or college educational attainment) that are representative of the type of occupations a child could reasonably have been expected to perform pre- and post-incident. Determine the ability to be educated (sometimes useful for people with acquired brain injury). Utilize relevant research data and computer analysis, as appropriate, based on family work patterns and/or client’s worker traits. This represents the client’s work life expectancy. Determine the amount of time that is lost, if any, from the labor force as a result of the disability. Issues include additional time to find employment, part-time vs. fulltime employment, medical treatment or follow up, earlier retirement, etc. Display data using specific dates or percentages. For example, the ability to work an average of four hours a day may represent a 50% loss.

occupational requirements (Parker, Szymanski, and Patterson, 2005). Employability, however, does not connote actual job placement potential, thus future earning capacity will depend on whether the client actually can be placed in a position for which he or she appears to be employable. Placeability refers to the likelihood that the client will secure and maintain work in a specific occupation (Gelman et al., 1957). The dynamics of placeability include the availability of jobs in a certain geographic area; the client’s age, sex, and race; employer attitudes; and specific hiring requirements (Parker, Szymanski, and Patterson, 2005). Job/task analyses, contact with local employers, and/or review of statistical information (e.g., from the Department of Labor, Census Bureau, etc.) are typically required to substantiate an opinion. Based on evaluation and situational assessment results, decisions regarding the least restrictive vocational placement can be made. Ideally employment outcome in an integrated labor market can be achieved; however outcomes may range from sheltered to competitive employment and include self-employment, telecommuting, and business ownership (Department of Education, 2001): Sheltered employment Sheltered employment is transitional and/or long-term employment in a controlled and protected environment for those who are unable either to compete or to function in the open job market due to their disabilities. Typically provided in private or community rehabilitation facilities that are certified by the Wage and Hour Division waiver to provide compensation at less than minimum wage level along with a mix of other services such as vocational evaluation, work adjustment services, day activity and/ or day habilitation programs 30 BRAIN INJURY PROFESSIONAL

Record Review

ACCESS TO THE LABOR

Determine the client’s access to the labor market. Methods include use of computer programs for transferability of skills (or worker trait) analysis, disability statistics, and experience. This may also represent the client’s loss of choice and is particularly relevant if earnings potential is based on very few positions.

Interview

REHABILITATION PLAN

Determine the rehabilitation plan based on the client’s vocational and functional limitations, vocational strengths, emotional functioning, and cognitive capabilities. This may include testing, counseling, training fees, rehabilitation technology, job analysis, job coaching, placement, and other needs for increasing employment potential. Also consider reasonable accommodation. A life care plan may be needed for catastrophic injuries.

EVALUATION

SYNTHESIS

Integrate results of the interview, parental/family occupations, educational attainment, evaluation results, developmental stage, and opinions regarding functional capacities to determine the impact of the disability and the likely options that are, within reasonable probability, available to the child. Consider any “pre-existing” or non incident related conditions that may have an impact on development, but are not appropriate to consider in a life care plan.

• • • • • •

Informationgathering

DEVELOPMENTAL

Consider the normal developmental tasks of a particular age (e.g., ADLs, career development). Determine the effects of a disability on function and ability to achieve developmental milestones. Provide recommendations for remediation and/or accommodations to facilitate the optimum level of function for the child.

• Personal interview conducted or requested? • Contact with collateral sources (e.g., family, friends, co-workers, employers) regarding post-injury function/changes? • Standardized interview format used? • Essential areas covered (e.g., medication intake; sleeping patterns; self-reported physical tolerances; age; interests; values; educational/employment background; specific vocational preparation; cultural, environmental, economic and psychosocial factors)?

• Consultation with team members (e.g., physicians, therapists, psychologists, or neuropsychologists)? • Appropriate referrals made to solicit additional information as needed? • Objective and relevant questions asked regarding function (e.g., physical capacity, effect of medication, understanding/memory, social interaction, sustained concentration/pace, persistence, adaptation, level of supervision required, compensatory strategies, assistive technology)? • • • •

Loss of earning capacity and wage-loss

EVALUATION RESULTS

Determine the child’s functional capacities through interviews and formal assessment of physical, cognitive, emotional and vocational capacity. Consider academic skills, interests, aptitudes, personality, assessment of independence/ADLs and family patterns of hobbies/leisure activities. When appropriate, compare to preincident status and function.

• Applicable records available for review (e.g., medical treatment, depositions, school records, test scores, vocational/employment records, tax returns)? • Client at optimum level of function? • Documentation of restrictions or limitations?

• • • •

Psychometric, vocational evaluation, and situational assessment considered? Specific referral questions provided (e.g., needed skills for a job, specific aptitude testing)? Results valid and appropriately interpreted? Results consistent and meaningful? Accurate comparison of pre- and post-injury function? Modifications or deviations from standardized testing protocols used when necessary?

Jobs accurately classified in the pre-injury transferable skills analysis (TSA) profile? Objective foundation for a Residual Functional Capacity (RFC)? Worker-trait factors appropriately adjusted? All aspects of vocational impact considered (e.g., physical demands, environmental conditions, cognitive capacity, emotional factors)? All relevant variables considered (level of education, work-life or labor-force participation, age, minority status, gender, job tenure, influence of appearance on earning capacity, and especially for pediatric cases, family influence)? Same guidelines applied to the evaluation of pre-injury education/earning capacity as post-injury education/earning capacity? Relevant costs for a rehabilitation or placement plan considered? Valid foundation for cost? Effect, if any, of the injury on work-life expectancy explained (e.g., delayed entry into the work force, less than full-time work participation, earlier retirement, expected increased turnover, time off for medical follow-up or treatment)?

Labor market research

EDUCATIONAL

Establish family patterns of educational attainment including information from the immediate and extended family (as above). Determine not only the academic level/degrees earned, but the skills obtained through education and training. Administer or coordinate a referral for achievement and/or intellectual assessment of parents as needed.

Vocational Process Questions

• If work potential, is a job analysis necessary? • Compensatory strategies considered (e.g., job coach, memory aids)? • Labor market research completed to justify a plan and/or conclusions (e.g., direct contact with employers, Internet research, published statistics)?

Opinion

PARENTAL/ FAMILY OC-

Obtain family work history (occupations and skill levels). Include information from parents, older siblings, aunts/uncles, grandparents and/or those adults that are likely to provide a role model for the child. Also include military experience, volunteer/community service, and/or avocational activities. Consider vocational assessment of parents, as appropriate, to determine a pattern of aptitudes or trait profile.

LABOR FORCE PAR-

• • • • •

Quantitative and qualitative data, triangulation of multiple sources considered for Opinion Validity©? Based on sufficient facts or data that is commonly relied upon? The product of reliable principles and methods? Principles and methods applied reliably to the facts of the case? Opinions within the expert’s level of expertise? Note: Adapted from Life Care Planning Questions Regarding Vocational Needs (Weed, 2004), Vocational Impact Worksheet Checklist (Weed, 1989), Earnings Capacity Checklist (Weed, 1990).

Supported employment Supported employment is work in an integrated work setting for individuals who, because of their handicaps, need ongoing services such as a job coach, employer support, transportation, assistive technology, specialized job training, individually tailored supervision and/or other job modifications or technology to facilitate success. Benefits and wages are the same as those received by other workers in similar jobs. Models include individual placement, enclave, mobile work crew, and small business (US Department of Labor, 1993). Volunteer activities Volunteer activities are nonpaid tasks within a competitive work environment for which no compensation is received. Activities may be part of a situational assessment process or an ultimate goal. Competitive employment Competitive employment is work in the labor market that is performed on a full-time or a part-time basis in an integrated setting without any special intervention or support services, and for which the individual is compensated at or above minimum wage but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals who are not disabled. Selective placement may be necessary whereby employment is offered to an individual commensurate with his or her physical or mental impairments. This involves intervention by a rehabilitation counselor to match an individual who has been injured with a particular job vacancy and help them secure the job, typically after labor market research and/or a job analysis have been completed.

The vocational expert may also make recommendations as to the manner in which the individual who has been injured can reach his or her optimal level of function, including identification of accommodations or modifications to the work environment that would enable a safe and productive return to work. The effect of brain injury sequelae on vocational capacity There are many possible sequelae of acquired brain injury. Most impairments are caused by damaged neurons from ischemia and diffuse axonal injury (Barth et al., 1983; Levin et al., 1987; Fork et al., 2005). Changes in neurocognitive abilities are common and include deficits in: • General intelligence • Language: receptive and expressive • Memory (encoding, processing, retrieval) • Motor skills • Sequential processing of information • Executive skills and abstract reasoning • Visual-spatial abilities • Problem-solving skills • Learning ability • Auditory/tactile perception • Attention and concentration A profile of the neurocognitive functioning of the individual with an ABI can be determined by neuropsychological testing that addresses the above issues (Golden, 1984; Barth et. al., 1983; Kane, 1991). The changes, in many cases profound changes, which individuals who have sustained an ABI almost always experience, include an emotional or behavioral component in addition to cognitive impairments (Mateer, Sira, and Connell, 2005). Thus, depression and anxiety disorders must be considered. As these deficit areas interact with the person’s pre-morbid set of personality factors, various sets of social skills emerge in the recovering person. Often these impaired or odd social interaction styles have profound effects on a person’s ability to obtain and maintain employment (Kregel, Parent, and West 1994; Mateer, Sira, and Connell, 2005; Prigatano, 1986; Prigatano, 2005). Physical impairments of a neurologic basis such as paresis (weakness) and loss of coordination in the extremities, increased tone or contractures in the extremities, loss of sensation, ataxia, and impairments of proprioception are common in severe brain injury (Zasler, 1999). With severe brain injury, it is possible to lose the senses of smell and taste, have hearing impairments, and experience a wide variety of visual disorders including field loss, diplopia, poor visual tracking and visual attention, and impaired acuity. Physical impairments are found less often in individuals with mild brain injury, but often subtle problems with decreased dexterity or speed of processing may have physical manifestations (Kay et al., 1992; Evans and Ruff, 1992). Changes or impairments of sensory systems are not uncommon. The most common sequelae of post-concussive disorders include problems with subtle changes in personality, attention and concentration, headaches, fatigue/ reduced energy, anxiety and/or depression. Vision is the most common sensory modality affected (Kay et al., 1992; Evans and Ruff, 1992). Evaluation issues Many traditional evaluations involve assessment of a client with ABI through single point or static evaluations that provide information about the person’s function in a certain environment during a specific time frame (Evans and Preston, 1990; Preston, Ulicny and Evans, 1992). The most common scenario includes gathering historical information about function from various sources (e.g., medical records, reports from client and family, etc.), completion of a physician’s examination with recommendations (typically a physiatrist or a neuropsychiatrist), a neuropsychological evaluation, and when available, information from physical, occupational and speech therapists. The experienced neuropsychologist is instrumental in profile interpretation and should be able to distinguish function areas that are impaired relative to pre-morbid function. Checklists such as the Neurobehavioral Functioning Inventory (Kreutzer, Seel and Marwitz, 1999), which includes questions regarding misplacing things, losing track of time, missing appointments, forgetting phone numbers, and word finding difficulty, as well as emotional/behavioral issues such as break-

ing or throwing things, feeling hopeless and threatening others, may be used. Consultation with a neuropsychologist or physician to rate mental function as it pertains to work tasks is useful to provide a vocational interpretation of neurocognitive results in the areas of understanding and memory, social interaction, sustained concentration, and persistence and adaptation. For example, an adaptation of the Social Security Mental Residual Functional Capacity Form (Social Security Administration, 1989) is available at www.nabis.org/bip/. Information regarding physical restrictions may be gleaned from physical/ occupational therapy assessments, specifically requested through a functional capacity evaluation or obtained from physicians. An estimated work capacity form may be used to organize recommendations to mirror components of a Dictionary of Occupational Titles (DOT) worker trait profile. (Blackwell, Conrad, and Weed, 1992). Physical and occupational therapists may also provide details regarding community function, activities of daily living (ADL) or instrumental activities of daily living (IADL) needs, adaptive equipment, and compensatory strategies based on assessment and intervention. Unfortunately, use of a transferable skills analysis, as in a traditional vocational assessment, often is minimally, if at all, helpful for a person with ABI and could lead to gross inaccuracy in projecting employment and wage earning capacity. Transferable skills are occupationally significant characteristics not directly affected or eliminated by disability status (Deutsch and Sawyer, 2004). The transferable skills assessment can be used to establish vocational goals by identifying job placement alternatives that can be immediately pursued. According to the Code of Federal Regulations, transferability of skills is most probable and meaningful among jobs in which the same degree of skill is required (or in which the new job requires less skill); the same or similar tools and machines are used; and the same or similar raw materials, products, processes, or services are involved. In most cases, the physical and environmental demands of a job are compared to an individual’s residual worker trait profile. Due to the complexity of cognitive and behavioral deficits, the limited number of data points in the traditional worker-trait model that cover cognitive and behavioral function does not provide sufficient information to make accurate assessments of their effect on vocational function. In addition, the authors have not identified through literature reviews, research and professional practice any valid method to make a statistically accurate correlation between neuropsychological test results and worker trait factors within the Vocational Diagnosis and Assessment of Residual Employability (VDARE)based TSA system. For example, the DOT worker trait profile allows for adjustment of physical and environmental demands, temperaments and aptitudes, but there is not a 1:1 correspondence between neurocognitive testing and rating levels of general learning ability, reasoning level, temperaments, or aptitudes such as spatial perception or finger/manual dexterity. Although the more recent O*NETsystem (2005) delineates multiple cognitive ability categories (e.g., fluency of ideas, perceptual speed, speed of closure), there is still no mechanism to complete a valid transferable analysis for cognitive limitations. Collaboration research is needed to develop analysis methods and valid correlations between data, and O*NET cognitive abilities. The most indirect method of obtaining information regarding real work behavior is psychometric tests; yet they represent the major source of information for many evaluations. Psychometric tests represent samples of behavior in a reasonably controlled situation that may have a weak relationship to daily behaviors in other situations. In almost all cases, testing is a sample that only represents a part of the criteria behavior to be predicted. For example, neuropsychological measures tend to be better at predicting failure than success and generally are more applicable to the prediction of performance in occupations with high cognitive demands (Sbordone, 1996). Ecological validity or the functional and predictive relationship between an individual’s performance on a set of neuropsychological tests and the individual’s behavior in a variety of real-world settings (e.g., home, school, community) must be demonstrated for a set of conclusions/recommendations to have relevance and validity (Sbordone, 1996). Tests must be germane to the demand characteristics of the various settings being considered. Unfortunately, many standardized functional capacity, vocational and neurocognitive assessments are administered in an environment free of extraneous stimulation which may not permit an individual to exhibit pathognomic behavior or represent the type of stress encountered in a work or community setting. Interactions between an examiner and client may mask cognitive and beBRAIN INJURY PROFESSIONAL

havioral impairments because some tests are designed for determination of optimal performance (e.g., with cues, prompts, and encouragement), while others do not allow for testing the limits. Representative norms may not be available for certain populations (e.g., for individuals who are Hispanic). Given the wide variety of behavioral demands in a job environment, what does a particular score on a neuropsychological test really tell us about function in a real-world setting? Information about behavioral performance factors for individuals who have an ABI and evaluations of their home and community function are often lacking. It has been found that evaluation and information on the person’s ability to effectively perform independent living functions such as time management, money management, and community mobility can be very telling with regard to how the person who has been injured is able to implement their residual skills into a pattern for daily living, and eventually, employment (Preston, Ulicny, and Evans, 1992; Preston, 1993. For this reason, thorough collateral interviews with family, friends, and employer/co-workers are essential. Issues to consider include a description of pre-morbid cognitive, behavioral and emotional function; personality traits; and aptitudes/skills contrasted with post-injury observations. In addition to interviews, situational assessment can improve the predictive accuracy of any vocational assessment. How does an individual problem--solve when given real-world issues and dilemmas such as a change in the bus schedule? Can they perform work tasks successfully over a four-week period? Specifically designed situational assessments (e.g., observation of executive function or a non-structured task) and work trials can provide the best information about how certain impairments impact a client’s ability to perform job tasks over time. Behavior and social functioning also can be observed. Situational assessments may be provided through brain injury rehabilitation programs, vocational centers where job tasks are monitored by life skills trainers and supervisors or through supported employment systems where a job coach assists the employee on the job site at the point of performance. Based on evaluation results, the vocational expert is charged with making projections that target the most likely post-injury occupations for an individual. Data from a variety of methods and resources (e.g., test results, interviews, observation, situational assessment, and work trials) must be utilized to determine the most likely residual functional capacity for an individual (Barros-Bailey and Neulicht, 2005). Outcome issues Statistics on competitive employment after a significant brain injury are not optimistic. The percentage of those that return to work ranges from 10% - 70% (Cifu et al., 1997). Multiple prognostic factors have been studied including the severity of injury, demographics, cognitive deficits and personality change, psycho-social adaptation, physical disability, work/education history, access to rehabilitation services, functional status, and employer attitudes (Crisp, 1992; Samra-Grewal, 1999). Although results of predictive studies vary widely and are likely due to methodological issues such as a lack of uniformity in severity ratings, lack of consistent operational definitions of outcome (e.g., successful employment) and variations in the follow-up time period (Fraser and Wehman, 1995), identification of individuals at risk for poor employment outcomes can facilitate rehabilitation planning and intervention (Kreutzer et. al., 2003). There is consensus in the literature that the more severe the injury, the less likely it is that the individual will return to work. Although seemingly apparent, severity per se may be of less value in predicting return to work than the precise effects of injury. Cognitive and behavioral/emotional changes are the main sequelae of brain injury that have been implicated as important predictors of outcome (Humphrey and Oddy, 1980; Thomsen, 1984; Weddell, Oddy and Jenkins, 1980). A number of studies conclude that psychosocial difficulties make a greater contribution to overall disability than do physical deficits (e.g., Oddy and Humphrey, 1980; Oddy et al., 1985; Jacobs, 1988; McKinlay and Brooks, 1984; Brooks et al., 1986; Sander, Kreutzer and Fernandez, 1997) and that the primary factors leading to job loss are the neurobehavioral deficits displayed on the job site (Kregel, Parent and West, 1994). In addition to psychosocial deficits, problems in thinking, reasoning, information processing speed, attention, concentration, and short-term memory are also recognized as formidable vocational barriers (Fraser, McMahon and Vogenthaler, 1988; McMahon and Fraser, 1988; McMahon and Shaw, 1996). Even if an individual has the skills to obtain a job, sustaining employment may be a concern due to changes in work duties or conditions, new colleagues 32 BRAIN INJURY PROFESSIONAL

or superiors, and/or diminishing employer support (Pössl et al., 2001). Consistent with the rehabilitation literature, persons who have sustained a brain injury and are able to return to their pre-injury job have greater success than those attempting to learn a new job (Asikainen, Kaste, and Sarna, 1998) or those changing both employer and the nature of employment (Johnson, 1987). However, while an overwhelming percentage of individuals with mild traumatic brain injuries may return to work, they do so with symptoms (Wrightson and Gronwall, 1980; Englander et al., 1992; Ruff, Camenzuli, and Mueller, 1996). Studies also reveal frequent job changes (Thomsen, 1984), shifts from full-time to part-time work, or to sheltered employment or volunteer work (Harrick et al., 1994), changes in level of responsibility and independence (Brooks et al., 1987), and the need for job modifications or a completely different job (Preston, Ulicny, and Evans, 1992). For example, Brooks and his colleagues found that while younger individuals with higher levels of education returned to (pre-injury managerial/technical) work, they were not working at full capacity, and colleagues were covering up for the mistakes made due to incapacity. A final outcome is not always possible to determine until years after a brain injury and often requires the assistance of a rehabilitation and re-employment program (Asikainen, Kaste and Sarna,1998). Current evidence regarding the benefit of rehabilitation shows a positive trend (Hall and Cope, 1995) with vocational supports and use of the therapeutic relationship as outcome factors (Evans and Ruff, 1992; Gamble and Moore, 2003; Johnstone et al., 1999). The importance of functionally relevant information (Rappaport et al., 1982; Gollaher et al., 1998), models such as intervention-consultation (Conder, 1989), vocational assessment as a goal-directed mechanism (Fraser and Wehman, 2001), graduated unpaid work trials, and a return to work plan that provides for accommodation as needed (Mclauglin et. al. 2005), as well as identification of environmental barriers/supports and extended follow-up (e.g., Wehman, Sale, and Parent, 1995; West et al., 2005, Whiteneck, Gerhart, and Cusick, 2004) must be considered in providing services to achieve an optimum outcome for individuals. Other studies of ABI vocational outcomes have focused on the effects of rehabilitation services on return to work and stability of employment. Success is linked to transdisciplinary evaluation, vocational evaluation with situational work assessment, job analysis, trial placement, job coaching/employer support, and community networking (Evans and Preston , 1990; Fraser and Clemmons, 2000; Brantner, 1992; Preston, Ulicny, and Evans, 1992; Wachter, Fawber, and Scott, 1987; Vandiver, Johnson, and Christofero-Snider, 2003). Even when clients with ABI are successfully placed into appropriate work environments there remains the critical issue of job maintenance over extended periods. Most studies demonstrate that placement needs are intensive and recidivism is high. For example, Wehman et al. (1995) report that in the supported employment model where a job coach is provided on a long-term basis, job stability is attained when the weekly staff time required for job maintenance falls below 20% of the client’s weekly work hours and remains below 20% for four consecutive weeks. Mean intervention time from placement to stabilization is 127 hours for the initial placement and 140 hours for the second placement, plus additional time for extended services. Second placements were considered almost normative, and the total number employed at 12 months was 51%, including both initial and second or subsequent job positions. Wehman recommends that return to work in supported employment “should be conceptualized as labor force participation, using measures such as the employment ratio, rather than single job retention.” Similarly, the concept of worklife expectancy and issues related to labor force participation are also components of loss of earning capacity opinions developed by vocational experts While return to gainful employment has been adopted as a primary measure of recovery in the literature, other outcome measures such as the quality of personal relationships and leisure activities may be of primary importance to an individual or family (Humphrey and Oddy, 1980), and feelings of success may be achieved even without paid employment (Levack, 2004). Rehabilitation necessitates the exposure of the individual to increasingly demanding situations which approach the reality of the work place. Services must be provided as part of a comprehensive intervention plan that focuses on relevant issues for the whole person. When appropriate, volunteer, recreation and/or avocational activities should be encouraged to facilitate independence and enhance self esteem.

Loss of competitive edge Loss of competitive edge can be defined as an impairment of function due to brain injury that reduces the person’s ability to compete for work in an open labor market. This is certainly “vocational disability” in the traditional sense of the term but it is also qualitatively different. Although many individuals with an ABI have some physical impairment, e.g., hemipareses, increased tone, antalgic gait, ataxia or dysarthria of speech, many have no visible signs that alert the general public that they have been injured. For this reason, a non-penetrating traumatic brain injury (the term that has replaced “closed head injury”) is often called the “unseen injury” (Kay, 1986) or a “miserable minority” (Ruff et al., 1996). The person with a mild brain injury may be able to walk, talk, get dressed, and drive a car. However, impairments are often centered in the behavioral-emotional-cognitive-social cluster (BECS), and the individual may have lost some “critical overhead” room in his or her functional capacity. This functional cluster often leads to significant problems with social skills (Kregel, Parent and West, 1994; Pössl et al., 2001; Mateer, Sira, and Connell, 2005). In the competitive labor market, a strong combination of cognitive capacity and soft skills provides the most sought after employee profile. Critical vocational behaviors include job objective, job-getting and job-keeping behaviors coupled with social, community, general and personal living competencies (Krantz, 1971). An individual must have a vocational goal that is appropriate, seek work frequently enough, demonstrate appropriate interview behaviors, attend work regularly, be prompt, behave appropriately toward coworkers and supervisors, as well as produce enough work that meets appropriate quality standards. In addition, money management, acceptable grooming and appearance, legal issues, housing, medical issues, transportation and family relationships must be managed appropriately. Interpersonal skill and personal qualities are also identified as workplace competencies by SCANS the Secretary’s Commission on Achieving Necessary Skills (US Department of Labor, 1998). In a study in the Journal of Applied Psychology, cognitive ability and accuracy skills were ranked highest, but the personality traits of agreeableness and conscientiousness were also considered very important (Neuman and Wright 1999). Researchers in the field of human resource management have noted that often a worker’s personality and related aspects are the most critical features in a worker’s capacity to maintain employment and upward mobility within an organization. According to Morem (2005), a worker’s ability to land, keep or move ahead at a job does not come from technical skills but a likeability factor (e.g., enthusiasm, getting along with people, etc.). The Center for Career Opportunities at Purdue University (2002) provides students information under the title Soft Skills: A Key to Employment Today.. Their information defines soft skills as “…the cluster of personality traits, social graces, facility with language, personal habits, friendliness, and optimism that mark each of us to varying degrees.” Persons who rank high in this cluster, with good soft skills, are generally the people that most employers want to hire. Soft skills are an important complement to hard skills, i.e., the technical requirements of a job and persons who rank high in this cluster are generally the people that most employers want to hire In cases where the impact of behavioral, emotional and cognitive deficits must be explained to a judge or jury, it is incumbent on the vocational expert to be able to clearly delineate the issues and provide examples and literature that helps illuminate the effect of specific issues. The traditional vocational evaluation is only marginally equipped to address the cognitive and behavioral issues of persons with acquired brain injury and therefore is at risk for overestimating the injured person’s true capacity for successful competitive employment. All orthopedic and physical factors are considered in the vocational assessment to determine changes in access to the labor market, placeability and earning capacity. However, a much more thorough investigation is required to accurately determine the vocational capacity and earning capacity of people with acquired brain injury. The neurocognitive profile can be essential in delineating problems areas which in turn will impair a person’s competitive work capacity. With each impaired or altered cognitive and emotional area comes a potential price in a person’s ability to compete across a range of cognitive skill parameters. Key cognitive skills that appear to be both commonly impaired in ABI and critical for competitiveness include: • Sustained attention • Complex/alternating attention

• Memory and learning (verbal and visual) • Reasoning, problem solving • Executive function (planning, organizing) Emotional overlays of depression and anxiety are common. The emotional and mood problems after ABI appear to be related to a combination of organic injury (probably primarily related to frontal lobe injury) and response to change in function, or problems with adjusting to the disability. In some cases this behavioral-emotional-cognitive-social (BECS) cluster of impairments leads to misperceptions and self-perpetuating anxieties in work situations. Many individuals with ABI are quick to anger, feel irritable, and may speak out before considering the implications of their words. Work stressors that the individual with an ABI considered commonplace before the injury may now become devastating emotional challenges that are not only impairing in their own right, but also cause the individual to act in a way that negatively affects how co-workers perceive them. The vocational expert must look not only at the BECS cluster but also at the work place behavioral expectations and integrate the deficit/demand interaction for each individual situation. These issues relate directly to both “placeability” and “labor force participation,” two key features of the RAPEL method of determining loss of earnings capacity. Often a successful job placement strategy includes providing extensive evaluation, situational assessment, selective placement, and employer supports to accommodate BECS cluster impairments. Extended (and repetitive services) may be needed, as well as a benevolent employer who offers special assistance or provide extra time to complete projects. Summary and conclusion Vocational experts tasked with providing a defensible opinion about the effect of a brain injury on the current and future vocational functioning of an injured person must be knowledgeable regarding the brain injury literature and be able to articulate how obvious as well as “unseen” behavioral-emotional-cognitive-social elements impact job acquisition and maintenance in a competitive labor market. In the high-stress American economy, those workers with a competitive edge are typically the ones who are most successful. For people with ABI, impairments of behavioral, emotional, cognitive and social function may preclude a return to gainful employment or cause them to lose their competitive edge to a significant degree. The effect may be a loss of access to jobs, loss of labor force participation due to frequent job changes or loss of opportunity for advancement (e.g., an inability to compete with work peers for promotions). Selection of a qualified vocational expert demands consideration of appropriate education, work experience, professionalism; and the use of specialized techniques to formulate an objective and defensible opinion. Giving an opinion that someone is not employable or placeable based solely on psychometric testing provides only part of an outcome statement and rarely restores an individual to as close to pre-injury capacity as possible. Extended assessment, in real-world situations, and identification of compensatory strategies as well as needs for long-term support must be considered.

About The Authors

experience as a Rehabilitation Counselor, Case Manager, and Educator. Her consulting practice focuses on Life Care Planning, Vocational/ Earnings Capacity Assessment, Labor Market Analysis/Job Placement, Case Management and Career Development. She is a Master Instructor for the Career Development Facilitator curriculum and the Vocational Counselor for the Work-Life Readiness Program for Start-Up Adults at the UNCCH Center for Development and Learning. She is under contract to the Social Security Administration as a Vocational Expert and has qualified as a Rehabilitation and/or Life Care Planning Expert in Workers’ Compensation Hearings as well as Superior and District Court. Research projects include a survey of Labor Market Research/Employer Sampling methods, the Life Care Plan Survey 2001 as well as Project COMPUTE and Project Techwork; grants which enhanced the employability of individuals with developmental disabilities through computer training.

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Personalized Success

Programs include: Neurobehavioral Rehabilitation Community Re-entry Supported Independent Living Day Treatment Services Vocational Rehabilitation Cognitive Remediation

No two brain injuries are alike. That’s why Bancroft NeuroHealth’s brain injury programs offer individualized short-term, long-term or lifelong services. Our neurobehavioral treatment models are designed to help transition individuals from more medically-based settings to more independent, community-oriented activities. A full continuum of residential and rehabilitation services allows us to design programs to meet each individual’s needs and flexibly adapt to changing needs. Our clinical expertise and compassionate care help those we serve to successfully rebuild their lives.

For more information: (800) 774-5516, or visit www.bancroftneurohealth.org 425 Kings Highway East, P.O. Box 20 • Haddonfield, NJ 08033-0018 Bancroft NeuroHealth, a New Jersey Non-Profit Corporation

Bancroft’s Brain Injury programs are accredited by CARF: The Rehabilitation Accreditation Commission. BRAIN INJURY PROFESSIONAL

by Brian Preston, MS, CRC, CLCP, ABVE-D and Nathan Zasler, MD, FAAPM&R, FAADEP, DAAPM Residential rehabilitation assessments come in all shapes and sizes based upon the specifics of the program as well as the expertise and level of cohesiveness of the treatment team. Ideally, residential programming should occur in a community-based program that has a relevant therapeutic milieu in terms of evaluating “real life” performance in an ecologically valid manner. Programs that are geographically isolated and not “in community” often have insurmountable challenges facing them in terms of performing ecologically valid community-based assessments. In comparison to what might be accomplished in an outpatient clinic setting, life care planners can gain more valuable information from an assessment that occurs over a longer period of a time and in a real-world environment. Residential Brain Injury Programs There are several types of brain injury rehabilitation formats available to persons with acquired brain injuries (ABI) and their families. Hospital-based rehabilitation programs are primarily utilized for acute care soon after the initial brain injury has occurred. The client may transition to a post-acute residential rehabilitation program, outpatient or day treatment program, and eventually either to home or to some type of extended rehabilitation or supported living program. The course of recovery will vary with each individual and depend on factors such as the neuropathology type, the presence and extent of secondary brain injury, and the duration of loss of consciousness. Additional recovery may occur over a number of years post-injury as the individual adjusts to his or her impairments and develops functional compensation for related deficits. Spontaneous neurological recovery was traditionally believed to occur up through 18 – 24 months post-injury; however more recent research has demonstrated that neurological recovery timeframes may vary from months to many years depending on variables such as the primary neuropathology, extent of secondary brain injury, and acute prognostic parameters. At the same time, it is generally accepted that improvement of function through adaptation and compensation for deficits can occur for many years post-injury and clearly beyond the time of neurological plateau. Consensus would dictate that it is reasonable to consider the development of a life care plan (LCP) to project current and future needs once the claimant/patient has reached at least a neurological plateau (although there are certainly situations where an LCP would be appropriate earlier post-injury). Because the ultimate outcome level may be a moving target early in recovery, the life care planner may need to use published literature on ABI 36 BRAIN INJURY PROFESSIONAL

outcomes in addition to specific clinical projections in order to project future needs. The life care planner may also need to specify that the plan should be revised as changes in patient/claimant status occur. An admission to a residential post-acute rehabilitation program can be extremely helpful in determining the capacity of the injured person to safely live independently. In addition to basic physical and cognitive functioning, such assessments can provide insight into complex living skills such as self-medication, time management, social skills, and stability of mental health over time. Many residential brain injury facilities are set up as a home-like atmosphere or similar to a small community college with a campus and several buildings in an urban or sub-urban setting. These programs often have 24-hour direct support staff such as life skills trainers (LSTs); clinical case managers; a nurse; licensed physical therapists, occupational therapists, speech-language pathologists and psychologists. Part of the treatment team may include at least one physician, usually a physiatrist, neurologist, or neuropsychiatrist. A typical supported living program may be a single-family home able to accommodate three to eight clients with LSTs providing 24-hour direct care, a clinical case manager, and access to therapists and medical specialists as needed. Another version available in the post-acute continuum is the supported apartment program, which provides an apartment in the community with daily staffing and support. In each of these living environments, the clients are provided with a daily schedule of therapies and activities that are designed to help the client improve skills needed to reintegrate into the community. Access to recreational and productive activities or vocational programs is typically part of the weekly client schedule. For each activity or therapy, staff is provided to assist the client and observe and document the client’s progress toward rehabilitation or behavioral goals. Medical care is provided by weekly and monthly nursing assessments, regular visits by a physiatrist or other physician, and by any needed specialist in the local community that may be required, e.g., an ophthalmologist, neurologist, or psychiatrist. The facility case manager will usually be the professional who coordinates the medical appointments and ensures that their client is receiving the services that are required and that all parties are communicating effectively. An activities coordinator, typically an occupational or recreational therapist, organizes daily goal-oriented therapeutic activities and works with LSTs to coordinate extension activities. These latter activities are designed to work on particular therapy goals such as improving range of motion, strength or motor control in the upper extremities, or remembering the sequence of steps

in preparing a meal or planning a shopping trip. Productive activities may be organized in the program so that the client assists with certain tasks in daily operations, such as vehicle maintenance, clerical tasks, or kitchen duties. Access to community programs such as horticulture, art, and music therapy may be provided. “Affirmative Industry” programs provide clients a chance to help operate a company that produces products or crafts sold in the community (Fraser 1990). All of these components of residential brain injury programs provide opportunities for understanding how the individual with the brain injury functions in the real world and the degree of his or her true abilities and deficits. Sometimes the person with brain injury does not have access to a comprehensive residential program because he or she cannot afford it and does not have insurance coverage for the treatment/assessment. The client, due to the aforementioned restrictions, may end up placed in a group home for individuals with developmental disabilities or even in a nursing home, often placed with geriatric patients and sometimes even on an Alzheimer’s unit. Obtaining comprehensive assessments of function in these types of facilities will be more challenging, and the information obtained typically will be more limited. The life care planner may need to make recommendations for additional evaluations by medical specialists such as neuropsychiatrists, neurologists, physiatrists, or therapists in order to obtain information helpful to the planning process. Funding is provided through a number of resources for specialized residential rehabilitation programs. Many residential programs receive funding for clients with brain injuries through workers’ compensation insurance, accident and health insurance, and funds from liability claims or settlements. Some states have Medicaid waiver programs that allow for limited public funding. Most often the life care planner is involved in cases with pending liability funds. In some of these cases, residential rehabilitation programs may be able to work with the attorneys to provide services on a lien basis so that the client can receive services prior to any settlement from liability. In most of these cases, external catastrophic case managers are involved to ensure that the client receives the proper services and that funds are being used appropriately for the client’s best interest. Life Care Planner Needs Life care planners need the best information available to project future care needs. Often treating physicians and therapists can offer only best-guess responses to the life care planner about how a person with ABI may behave in real-world situations over an extended period of time. Without information from a residential facility, the family report is often the best data source for information regarding changes or problems with cognitive skills and behaviors in various community settings. Independent medical examiners may have even less access to such data even though they may be asked to give opinions about the effect of behavior on future independent living and/or vocational functioning. In order to improve the accuracy of projections for cognitive, behavioral and social functioning and the need for particular types of community or facility supports, a residential rehabilitation evaluation (RRE) should be considered. Such evaluations take several weeks to complete. The authors have found that a three to six week assessment is usually the minimum recommended period of time required to answer many of the typical questions posed by a life care planner. (These recommendations are guidelines only, are based on the experience of the authors and do not necessarily reflect the opinions of other brain injury providers.) As discussed below under “Medical Aspects of the RRE,” longer lengths of stay typically provide more information about complex community functioning, as well as a better understanding of emotional and behavioral stability. Because not all residential programs provide time-limited evaluations or separate evaluation services, life care planners should become aware of the resources in their region. Advocacy and educational associations such as the Brain Injury Association of America (BIAA) and its state chapters, the North American Brain Injury Society (NABIS) and the International Brain Injury Association (IBIA), as well as professional case management organizations such as the International Association of Rehabilitation Professionals (IARP) and Case Management Society of America (CMSA) can provide both resource directories and valuable professional experience helpful in selecting such programs. The life care planner may be involved directly in making a referral to the facility or they may be able to recommend referral by the attorney or insurance company. Either way, it is important that the life care planner be involved prior to or close to admission so that specific referral questions

can be posed. It is helpful if the rehabilitation program is provided with the referral questions prior to or at the time of admission so that the assessment can be done in a timely manner. Questions that the life care planner may have that an RRE should be able to answer or provide some information about include: • Can the client perform his or her own activities of daily living (ADLs) safely and successfully? • What effect do cognitive deficits have on the client’s daily and weekly function? • Is the client able to safely manage his or her own medication administration? • How do a client’s emotional issues affect his or her daily function? • Can the client accurately follow a schedule and how does he or she manage unstructured time? • How well does the client get along with peers, staff, and people in the community? What are behavioral triggers that agitate the client and what is the best environment to minimize behavioral outbursts? • Can the client benefit from neuropsychiatric pharmacological interventions? • How much future physical therapy, occupational therapy, speech therapy and psychology services should be projected? • Can the client access the community safely? Can he or she use public transportation and successfully shop, and plan and make meals? Can the client manage his or her money effectively? • How much family support is available? What is the best long-term living environment for the client? How much and what type of home or facility support will he or she need? • What is the client’s degree of safety awareness and can the client effectively protect himself or herself in society? • What is the amount of support needed? • What type of lay, paraprofessional and/or professional must provide the help in question? The life care planner also should stay in touch with the facility clinical case manager and be prepared to attend facility team meetings so that issues can be discussed and additional questions asked to further clarify current and future needs. In addition, the authors propose that long-term follow-up of a client in a residential brain injury facility for whom an LCP has been prepared can provide a foundation for establishing the validity of LCP recommendations for individuals with acquired brain injury. Further research in this area certainly seems to be warranted. Medical Aspects of the RRE For medicolegal purposes, the bottom-line question is: What is more probable than not? It is our opinion that the shorter evaluation will generally allow an experienced and cohesive treatment team to develop a comprehensive list of medically necessary recommendations. Longer evaluations are indicated when there are concerns regarding the efficacy of prior rehabilitation efforts and/or the true rehabilitation/functional potential of the client. We often find that even clients who have been through extensive rehabilitation programs can benefit from longer-term transitional neurorehabilitation services if there is an aggressive interdisciplinary and transdisciplinary approach using a biopsychosocial model (e.g. an approach incorporating biological/medical, psychological and social aspects of the disease process and how it impacts the patient in question), as opposed to simply a psychosocial or purely medical model. Certainly the information garnered is more detailed, accurate, and specific when the period of evaluation is longer. The involved professionals can also speak with greater levels of assuredness regarding the likelihood that interventions will be necessary if they have had a longer period of exposure to and experience with the client. Part of the process in determining how long an evaluative period is necessary needs to be driven by economies of scale, and as previously noted, the purpose of the evaluation. A comprehensive program will provide for on-site physician involvement by a specialist experienced in ABI, e.g., a physiatrist, neurologist, or psychiatrist. A comprehensive physical examination by the program physician can be crucial in revealing ongoing neuromedical issues, as well as delineating impairments consequential to accident-related sequelae, whether secondary to brain injury or peripheral injuries. The assessment should be comprehensive and include evaluation of physical, cognitive, and behavioral impairments. A thorough evaluation should also take into account common problems seen in BRAIN INJURY PROFESSIONAL

Based on these types of assessments, the treatment team, and in particuthis patient population, including pain issues, post-traumatic affective disorders such as anxiety/PTSD, depression, and emotional reactions to blocked lar the neurorehabilitation physician, can provide the life care planner with normal activities and disability. Pain issues, and headache in particular, specific information regarding the nature, frequency and purpose of future should be evaluated thoroughly as should other somatic complaints such as consultations, medical and otherwise, as well as future diagnostic testing and visual impairments, sensorimotor impairments, chemosensory deficits involv- other interventions, including the potential for surgical procedures such as ing smell and taste, audiovestibular disorders, etc. Clinicians should avoid use shunt replacement. The role of neuropsychology and psychology within the context of a of generic diagnostic labels such as post-traumatic dizziness or post-traumatic headache because such labels say nothing about the underlying etiology of the residential rehabilitation assessment and the development of an LCP can be condition and serve no purpose in directing specific therapeutic interventions critical as the adept neuropsychologist plays an integral role in the rehabilitaor providing any prognostic information. Rather, they should provide etio- tion assessment and treatment process. A good psychologist who is experilogically-specific labels, such as: post-traumatic headache due to cervicogenic enced at developing behavioral programming that includes habit retraining referred myofascial pain in conjunction with right greater occipital neuralgia. protocols can be very helpful in the development of treatment recommenDepending upon the level of impairment of the client, evaluation may dations within the program or beyond the confines of program admission. require assessment of ongoing neuromedical disorders such as post-traumatic All too often, neuropsychologists focus on assessment rather than treatment. epilepsy, hydrocephalus, late intracranial extra-axial collections, and/or neu- The best residential programs utilize neuropsychologists who not only are roendocrine dysfunction. Significant physical impairments such as move- good diagnosticians but also provide individualized behavioral treatment ment disorders, ataxia, spasticity, joint range-of-motion limitations, and/or programming focusing on habit retraining and emphasize behavioral modicontractures should all be assessed and recommendations provided for mod- fication methods based on positive reinforcement and progressive shaping of ulation, with an eye toward providing functionally relevant recommenda- behaviors. A good neuropsychologist/psychologist can assist the treatment tions for the client. It is often necessary for the neurorehabilitation physician team, as well as the life care planner, in developing behavioral modification to order additional tests to clarify the etiology of claimed impairments; these recommendations that are relevant for the real world, and as part of these tests may include static as well as functional neuroimaging, various formats recommendations, provide input into what will be required to maintain the of EEG testing, audiovestibular testing including posturographic evaluation, programming once the client has left the program. Although neuropsychological testing in and of itself is an important component of the assessment neuropsychological evaluations, FCEs, etc. A sophisticated residential neurorehabilitation program team should process, testing results are not always ecologically valid in the context of realwork in a complementary fashion in order to be able to provide informa- world functions, and therefore it is just as important, if not more importion to the life care planner and assist in identifying specific client needs. tant, for the client to be observed “in community” by the members of the Information provided through nursing, case management, therapists, and team as well as by the neuropsychologist/psychologist and behavioral treatneurobehavioral specialists (the latter including neuropsychology, psychol- ment staff. Only in this manner can the client’s true behavioral deficits and ogy and behavioral support staff ) should be integrated into treatment team strengths be revealed. One of the benefits of a longer evaluative admission is that it allows for the better behavior that can occur during the so-called recommendations. In general, the evaluations from the facility medical director and neuro- “honeymoon period” to abate and for the more typical baseline behaviors to psychologist should help guide the evaluative process of the other team mem- manifest themselves. Ideally, a good residential neurorehabilitation program bers. Adequate rehabilitation management should include comprehensive will integrate the role of the neuropsychologist/psychologist with the entire assessment and treatment of any and all impairments that might be produc- treatment team, including participation in daily programming. The case manager (CM) typically serves as the point person for commuing functional disability that impedes optimal community independence. Appropriate medication management is crucial after ABI. Avoidance of nication with outside consultants, family, residential clients, as well as the life cognitively suppressing medications should be a priority. It is also important care planner. Interaction with the latter may occur in the context of clinical life care planning or forensic life care planning. The to minimize polypharmacy and improve medicaA list of recommended readings for this CM should provide regular summaries of treatment tion compliance by prescribing medications that can be taken less frequently. The ability of the article can be found at www.nabis.org/bip/ team recommendations as part of a regular report to involved parties, including the life care planner. prescribing physician to determine the long-term necessity of drug treatment interventions is critical in the context of provid- A good CM should also function as a conduit for information to be commuing recommendations to the life care planner. Clearly, drug management of nicated from the team to the life care planner and from the life care planner persons with traumatic brain injury (TBI) is in evolution, so what may be to the team and any other involved parties. As referenced previously, the life true today may not be true in five to ten years. These types of issues should care planner can best accomplish this communication through referral quesbe acknowledged upfront to the life care planner because they impact the tions and subsequent involvement with the treatment team, case manager, and ability of the physician to state the need for long-term drug prescription with physician. Whether for solely evaluative purposes or in the context of transitional a degree of medical probability versus a degree of medical certainty. It may also be necessary for the treatment team to request outside con- neurorehabilitation services or long-term assisted living, the treatment team sultation, either from a consultant affiliated with the program or an outside should provide the life care planner with details of a client’s functional level of independence, as well as the client’s needs relative to supportive services consultant. For example: • A neuropsychiatry consultation may help identify severe behavioral issues. such as general assistance with activities of daily living, mobility and/or com• A neurological consultation may help with the assessment and manage- munication, and social skills. The team also should provide input about the ment of post-TBI neurological impairments such as seizures, movement client’s need for and use of adaptive devices and equipment, and identify any specific safety/risk concerns and/or environmental barriers to successful disorders, and sleep disorders. • A neuro-optometry and/or neuro-ophthalmology consultation may help community re-entry. Direct care staff such as LSTs should be able to provide input of a more assess and manage visual impairments and related visual disabilities. • A urological consultation may help evaluate and manage neurogenic hands-on nature regarding a client’s level of functional independence. For bladder dysfunction (e.g., urgency, frequency, and/or incontinence) and example, they may have directly observed the client’s ability to self-admindetermine if pharmacologic and/or surgical interventions should be con- ister medications or budget money. They should have a good feel for the client’s judgment relative to general safety issues and the appropriateness sidered. • If communicating hydrocephalus is noted by the treating physician, a of social pragmatics and behaviors; and they may have observed indicators neurosurgeon could assess late neurological decline. Other reasons for of impulse control disorders and disinhibited social behaviors. Direct care neurosurgical consultation might include late subdural hematoma re- staff can and should also provide feedback to the team and life care planner quiring drainage, surgical evaluation for treatment of intractable epilepsy regarding the client’s continuous implementation of functional mobility inor movement disorders, or evaluation and remediation of intraventricu- dependence, management of unstructured time, self-care management, and problem-solving and decision-making in a variety of real-world situations lar shunt dysfunction. • A neuro-orthopedic consultation can be useful when there are issues re- such as shopping and use of public transportation. For patients with more significant cognitive and behavioral impairments, garding surgical management of contractures, ankylosis, and/or limb depresumptive or otherwise, the treatment team, including direct care staff, can formities/dysfunction due to spasticity and/or heterotopic ossification. 38 BRAIN INJURY PROFESSIONAL

provide feedback regarding whether or not the observed impairments are consistent with impairments associated with ABI as opposed to other factors such as affective disturbances in the form of anxiety and/or depression, or suboptimal effort and/or other functional etiologies. It is certainly critical in the context of the team’s recommendations to determine whether the client is presenting with valid and consistent types of complaints that would be in line with those expected from the type of injuries sustained. Without a holistic team assessment, including determining whether or not there is evidence of client response bias, the treatment team’s opinions will be of limited value. The treatment team’s recommendations should also encompass details as to whether or not there has been sufficient time for evaluation of the client relative to the questions being asked by the referring party. If the client is in the program longer term, e.g. for transitional neurorehabilitation services or long-term assisted living, then recommendations should be made to the life care planner as to whether the current level of service is sufficient to meet the client’s needs (i.e., in intensity, type and/or duration) or whether services can be decreased to be more cost effective but still meet client needs adequately. There may be occasions where the treatment team’s recommendations are disparate from the clinical opinions of the life care planner. In such cases, these disparities should be discussed in an open forum context. It should be understood that ethically the treatment team has no allegiance per se to changing its opinions to match those of a life care planner who is external to the program. As much as possible, the various parties should try to compromise on areas where there are differences in opinion. When compromise is not achieved, differences of opinion relative to treatment recommendations and specific line items in the LCP need to be acknowledged by those involved. The life care planner may be able to use disparate opinions to provide reasonable ranges or several options for future care needs, as both techniques are common practice in life care planning. Attorney Issues When life care planners are developing plans in a litigation arena, i.e., for claims of third party liability or worker’s compensation cases, there will always be attorneys involved who are seeking information to best support their case, whether they represent the injured party or function as the defense attorney for an insurance company. In many cases the life care planner is hired by the attorney and information obtained through the RRE is provided to the attorney through the life care planner. In other cases, attorneys may wish to be directly involved with the rehabilitation facility and may attend treatment team meetings or have frequent communication with the case manager. Plaintiff attorneys may want to access the facility for an RRE while developing their case prior to a settlement that would provide funds for the rehabilitation and long-term care needed for their client. Some specialty brain injury facilities agree to provide the RRE to the attorneys before the settlement in exchange for a lien on the anticipated settlement. A lien is a legal agreement that promises payment to the facility upon acquisition of funds. Because of the risk the facility incurs in this arrangement, it may want to consult with legal counsel before agreeing to such terms. Attorneys frequently request videotaping of their client in treatment to demonstrate not only his or her impairments but his or her degree of functional disability and need for assistance. Such videotapes are often used in settlement packages as well as at the trial. A specialized brain injury residential facility is an excellent place to film these day-in-the-life videos. Attorneys may wish to subpoena facility professionals as witnesses in their litigation as they move towards a trial. It is fairly common for physicians, psychologists, and treatment team members to be deposed regarding either their expert opinions or as fact witnesses in their evaluation. Treatment professionals may feel that being deposed by attorneys is an intimidating and stressful process that they wish to avoid. However, as either an expert witness or a fact witness, it is often the professional in a specialty brain injury program who can provide information that is critical to the life care planning process and ultimately helps the parties arrive at a fair and reasonable settlement. Conclusion Since life care planners are tasked with planning the care of an injured person over the person’s lifetime, they should seek the most comprehensive projective data available regarding the client for whom they are planning. Life care planners can obtain excellent projective data from specialized residential rehabilitation programs and supported living programs. The life care planner’s referral questions can help the brain injury facility focus

its evaluation efforts. In such programs, external insurance case managers and life care planners can follow the individual’s progress, and over time, increase their understanding of behavioral patterns that might not be readily apparent during the individual’s short-term assessments and clinic visits. Treatment team members and LSTs can make keen observations about variability of performance, behavioral triggers, social skills, response to treatment approaches, degree and intensity of support services needed, and the manner in which the client generalizes acquired knowledge into his or her daily living system. Facility team meetings and CM reports provide a wealth of knowledge about future needs as well as potential complications. Lastly, it is our experience that specialized community-based ABI programs, although underutilized for this purpose, can serve as excellent resources for life care planners. Specifically, such programs can provide vital objective data to both clinical and medicolegal life care planners that can serve them well in the development and evolution of their LCP documents and testimony.

About the Authors

Brian K. Preston is currently Regional Director of Learning Services of North Carolina, directing the management of 30-40 clients with acquired brain injury in community-based supported living and neuro-rehabilitation facilities in the Raleigh/Durham, North Carolina area. He is also president of Preston Rehabilitation Consulting providing vocational expert testimony and life care planning services in a variety of arenas. Mr. Preston holds a Master’s Degree in Rehabilitation Counseling from the University of North Carolina at Chapel Hill and is a Certified Rehabilitation Counselor, a Certified Life Care Planner and a Diplomate of the American Board of Vocational Experts. He taught case management and life care planning as an adjunct professor in the Division of Rehabilitation Psychology and Counseling at the University of North Carolina at Chapel Hill. He has published and presented extensively on the issue of vocational rehabilitation for persons with acquired brain injury, private rehabilitation issues and ethics in private rehabilitation. Nathan D. Zasler, MD, FAAPM&R, FAADEP, DAAPM is an internationally respected physician specialist in acquired brain injury (ABI) care and rehabilitation. He is CEO and Medical Director of the Concussion Care Centre of Virginia, an outpatient neurorehabilitation practice, as well as, Tree of Life, a living assistance and transitional neurorehabilitation program for persons with acquired brain injury in Glen Allen, Virginia. He is board certified in Physical Medicine and Rehabilitation and fellowship trained in brain injury. Dr. Zasler is a Clinical Professor of PM&R at VCU in Richmond, Virginia, as well as, a Clinical Associate Professor of PM&R at the University of Virginia, Charlottesville, Virginia. He is a fellow of the American Academy of Disability Evaluating Physicians, and a diplomate of the American Academy of Pain Management. Dr. Zasler has lectured and written extensively on neurorehabilitation issues. He is active in national and international organizations dealing with acquired brain injury and neurodisability, serving in numerous consultant and board member roles. He has co-edited four textbooks (“Rehabilitation of Post-Concussive Disorders”, “Medical Rehabilitation of Traumatic Brain Injury”, “Rehabilitation of Functional Disorders” and “Brain Injury Medicine: Principles and Practice”). He is on several journal editorial boards including Journal of Head Trauma Rehabilitation and Neuropsychiatric Disease and Treatment, among others. Dr. Zasler is chief editor of the international scientific publications “NeuroRehabilitation”, “The International Neurotrauma Letter”, and “Brain Injury”. He currently serves as the Chairperson of the International Brain Injury Association. His main areas of clinical and research interest include neuromedical issues in acquired brain injury (particularly mild TBI, neuropsychopharmacology and low level neurologic states), differential diagnosis in ABI, community-based care issues, as well as, chronic pain rehabilitation including headache. Dr. Zasler is a practicing clinician who is involved with community based neurorehabilitation and neuromedical assessment and management of persons with acquired brain injury, neurodisabililty, as well as, chronic pain. He is also involved in ABI healthcare consultation, both clinical and medicolegal.

REFEReNCES

Fraser R, Clemmons D and McMahon B: Vocational Rehabilitation Counseling. In Community Integration of the Traumatically Head Injured Adult. P Wehman J Kreutzer (Eds.) Paul H. Brookes Publishing Co., Baltimore, MD. Pages 169-184, 1990. BRAIN INJURY PROFESSIONAL

When one travels to the Dominican Republic, among the first bits of advice the “Locals” provide to the “Tourists”, is that “one should not sit under the coconut trees”.

Critical Thinking: Its Impact on Life Care Planning by Jan Roughan How the above admonition is perceived has a great deal to do with one’s nature, nurture, education, training, expertise, life experience and overall philosophy, as well as use of their critical thinking skills….in essence, their “point of view”, in respect to consideration of: information of this nature; information of this nature from an unknown source; information of this nature when one is in a “vacation” frame of reference and not wishing to consider too much, too seriously and so forth. We all realize that every social system grants its members some degree of freedom; and, that as H Brun tells us, freedom consists of the kind and number of alternatives open for “choice” to its members. He notes, however, that every choice made, leads, in turn, to a loss of freedom, as the structure of these systems tends, in consequence of the choice made, to render at least some not chosen alternatives, from then on, inaccessible to the individual(s) who made the choice. The freedom granted, therefore, reduces the freedom of those of its members who use it. Choice, then, results in loss of freedom… When pondering the above admonition, is there a correct, a right choice? In researching just how one arrives at a decision in respect to a matter such as that described above, we learn that Human thought is relational and selective; that it is impossible to understand any person, event, or phenomenon from every vantage point simultaneously; that our purposes, like it or not, often control how we see things (e.g., in the above instance, the mindset that it is a vacation that one is embarking upon; and, the desire to partake of the pleasure of sitting under the shade of the coconut tree vs. the admonition not to do so, due to the Local’s experience, that, inevitably, every Tourist Season “someone” sustains a Head Injury due to a falling coconut). Critical thinking requires that these facts be taken into account when analyzing and assessing the processing of this information. This is not to say that human thought is incapable of “truth” and “objectivity”, but only that human truth, objectivity, and insight is virtually always limited and partial, virtually never total and absolute. The hard sciences are themselves a good example of this point, since qualitative realities are systematically ignored in favor of quantifiable realities. What, then, is the outcome of exercising one’s freedom of choice by making a decision to ignore the above admonition? Maybe, simply a pleasant day on the beach and no untoward consequence; or, conversely, the encountering of a strong velocity impact to one’s head by a falling coconut, which weighs in the neighborhood of 1.5 pounds (680 grams); falls from a height of some 50 to 80 feet; and, potentially alters one’s life forever. “A point of view can be a dangerous luxury when substituted for insight and understanding”, or so says the Canadian communications Theorist Educa-

tor, Writer and Social Reformer, Marshall McLuhan (1911-1980). And, clearly, if one does encounter the falling coconut, one admittedly has engaged in a dangerous luxury; and, as a result, is subject to the consequences of their decision. The outcome of the latter choice is not atypical of that which impacts health care professionals as they attempt to accurately differentially diagnose and appropriately plan treatment for the unfortunate individual who ignored the admonition and encountered the falling coconut. We, as professionals, will likely be involved in determining the extent of the Head Injury associated with the falling coconut; whether a Brain Injury occurred as a result of the falling coconut; and, if so, the degree (i.e., Mild, Moderate, Severe) of the injury, as a result of the falling coconut; the implication of the injury in terms of functionality over the long haul; and, the consequent needs of the unfortunate individual. Point of view must once again be appreciated, albeit from a different perspective, from the professional’s perspective. Elements of critical thinking, such as “criterion”, “evidence”, “bias”, “analysis”, “assumptions”, “conclusions” “accuracy”, and “authority” come into play when determining the above. “Criterion/criteria”, according to the Critical Thinking Glossary, authored by the Critical Thinking Community, is defined as a standard, rule or test by which something can be judged or measured. The Glossary goes on to tell us that evaluation has a logic and that it should be carefully distinguished from mere subjective preference; that the elements of logic may be put in the form of questions, which may be asked whenever an evaluation is to be carried out: • Are we clear about what precisely we are evaluating? • Are we clear about our purpose? Is our purpose legitimate? • Given our purpose, what are the relevant criteria or standards for evaluation? • Do we have sufficient information about that which we are evaluating? • Is that information relevant to the purpose? • Have we applied our criteria accurately and fairly to the facts as we know them?* This same source defines “evidence” as the data upon which a judgment or conclusion might be based, or by which proof or probability might be established. The community of critical thinkers note that those who exercise critical thinking skills, distinguish the evidence or raw data upon which they base their interpretations or conclusions from the inferences and assumptions that connect data to conclusions; those who don’t, treat their conclusions as something given to them in experience, as something they directly observe in the world.

*The Glossary tells us, in fact, that uncritical thinkers often treat evaluation as mere preference or treat their evaluative judgments as direct observations, not admitting of error.

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They note that individuals in the latter group find it difficult or even impos- to certain subject matter believed to be relevant by those presumably expesible to describe the evidence or experience without coloring that description rienced in the field, it is then assumed that they are able to construct a credwith their interpretation. ible Life Care Plan; and, that they possess the authority to defend it/provide When considering the above, a look at “bias” is in order as well. What is expert testimony in its regard, if need be. it? The Glossary tells us that it is a mental leaning or inclination; that there are Why, then, are there differing opinions, different Life Care Plans, given two different senses of the word, one “neutral; and, the other “negative”; that the same case? We see this, not only from an applicant/plaintiff vs. defense in the neutral sense we are referring simply to the fact that, because thinking perspective (i.e., from those on opposites sides) but, as we note from the diawithin a point of view is unavoidable; in the negative sense, we are implying logue on the List Serve/LCP Forum, in many instances, amongst professionals blindness or irrational resistance to weakness within one’s own point of view of the same side and of the same discipline, as well. or to the strength or insight within a point of view one opposes. It tells us that Does the difference result from the combination of all the factors heretofair minded critical thinkers try to be aware of their bias (in sense one) and try fore discussed? Is it a matter of the variation in discipline and/or the focus of hard to avoid bias (in sense two); that many people confuse these two senses; a particular professional’s preparation (education, training, expertise, experimany confuse bias with emotion or with evaluation, perceiving any expression ence)? Is it the steps in the process one utilizes to arrive at conclusions and of emotion or any use of evaluative words to be biased (sense two); and, that determination of the content of the plan? Or, is it a combination of all of these according to the principals of critical thinking, evaluative words that can be elements? Probably, the latter. justified by reason and evidence are not biased in the negative sense. I note in the activity of simply engaging in the back and forth dialogue The Glossary tells us further, that in order to arrive at accurate conclu- of the Forum, that my approach to many of the questions, issues, problems sions, we “analyze”, or break up a whole into its parts or examine in detail, so differs from that of others….a recent example is a Life Care Planner on the as to determine the nature of, to look more deeply into, an issue or situation. Forum giving advice that the “aggressive” portion of the plan is solely within We, in essence, categorize and label things in one way rather than another, the purview of the physician. I disagreed, and noted that I felt it to be my again, largely depending on our point of view. We assume or take for granted duty, my responsibility, as well as that of the physician, in that it was incumor presuppose certain facts. bent upon me to assess the patient; to identify problems; and, to determine We, in essence, make “assumptions” (i.e., a statement accepted or supposed appropriate approaches to the resolution of those problems to the extent posas true without proof or demonstration; an unstated premise or belief). And, sible. I noted further that I would, then, consult with the physician expert to although, as the Glossary tells us, people often equate making assumptions determine his/her understanding of the same issue, as well as consider what with making false assumptions and admonish that we “shouldn’t assume”, we, their recommendations were in terms of resolution. However, if I felt the in fact, cannot avoid making assumptions, some quite justifiable (for instance, issue was not being adequately addressed, I would take further measures to it is assumed that people who buy this book can read English). These critical rectify the situation. thinkers tell us that rather than saying “never assume”, we say, “be aware and be My view of working with the physician in construction of a Life Care careful about the assumptions you make; and be ready to examine and critique Plan would be from a “consultative” and “collaborative” perspective, rather them”. It goes on to say that all human thought and experience is based on as- than that of a “deferrerential” perspective. My assumption would be that the sumptions; that our thoughts must begin with something we take to be true in physician may or may not know all of the facts that I have been privy to; and, a particular context; and, that we are typically unaware of what we assume and that I may be in a better position, simply from a time perspective, to gather therefore rarely question our assumptions. For example, we often experience certain information and conduct certain research to perhaps provide an exthe world in such a way as to assume that we are observing things just as they panded/more thorough database from which to draw conclusions. are, as though we were seeing the world without the filter of a point of view. An example of the above instance might be in respect to conducting what People we disagree with, of course, we recognize as having a point of view as I call “Collateral Interviews”, particularly in the event of a mild or moderate well; and, one of the key dispositions of critical thinking is the on-going sense Brain Injury. That is, I make an attempt to speak with both family members that as humans we always think within a perspective, that we virtually never and other individuals who knew the patient before and have continued to keep experience things totally and absolutely. in contact with him/her subsequent to the injury; and, as such, can attest to the The Glossary tells us that the last step in the reasoning process is the individual’s differences/changes in function, cognition, and/or behavior. formulation of a “conclusion”, in its pure form, a decision arrived at after When working with the brain injured, prior to engaging the “collateral” investigation, deduction, or judgment; and, that though all beliefs, decisions, source in an interview, I make it a point to determine the areas of the brain or actions are based on human thought, they are injured (coup; contre-coupe) and the potential rarely as the result of “conscious” reasoning or de- Visit www.nabis.org/bip to download ad- impact in respect to functionality, so as to have a liberation, and are, instead, based on conclusions ditional material relating to this article. “targeted” approach to my questioning. that we have come to during our lifetime that have In fact, in speaking with those who live and not been critically assessed to determine whether we have sufficient grounds interact with the patient on a day-to-day basis, one can ascertain other critior reasons for accepting them. The critical thinkers go on to tell us that cal factors as well, such as subtle signs and symptoms associated with Post most folks confuse their conclusions with evidence, and so cannot assess the Traumatic Hydrocephalus for example. I believe it to be critical to the Life reasoning that took them from evidence to conclusion. They admonish that Care Planning process to know the potential pathophysiology associated recognizing that human life is inferential, that we continually come to con- with Brain Injury; with all potential complications and their subtleties; the clusions about ourselves, as well as the things, persons, subject matter around fact that there can be something called Normal Pressure Hydrocephalus, a us, is essential to thinking critically and reflectively. condition that holds the potential to negatively impact the individual’s re“Accuracy”, according to the Glossary of Critical Thinking, means to be covery if not identified and dealt with; an undiagnosed seizure condition; an free from errors, mistakes, or distortion. The term implies a positive exercise inner ear dysfunction; etc. one utilizes to obtain conformity with fact or truth. Then, if we take it a step What I am saying here is that I believe the differences in a Life Care Plan further and look at being not just accurate, but exact, this same society of prepared by two individuals in respect to the same patient, for the most part, thinkers, tells us that this means to be in perfect conformity with fact, truth has to do with application of the elements of critical thinking. or some standard. Yet a step further, to be precise, suggests minute accuracy When it comes to Brain Injury for example, the critical thinker applies a of detail. This same source, however, cautions that it should also be recog- standardized process (use of the same thorough approach/steps each and every nized that some distortion usually results whenever we think within a “point time they analyze a case); assimilates the requisite evidence (use of a detailed of view” or “ frame of reference”, which one typically can’t help but do for assessment protocol pertinent to the diagnosis; obtaining critical information the afore stated reasons. from “collateral” interviews; etc.); analyzes the parts or pieces of information And, finally, a look at “authority”, or the power or supposed right to give vis-à-vis that of normal function (pre-vs- post morbid perspective); considers commands, enforce obedience, take action, or make final decisions; or, more the information; makes certain assumptions (based on a knowledge of the germane to the topic at hand, a person (e.g., the “expert” Life Care Planner), pathophysiology of the diagnosis with which one is dealing); then, arrives at with much knowledge and expertise in a field, hence reliable. The Glossary certain conclusions regarding a given individual’s needs. tells us that critical thinkers recognize that ultimate authority rests with reaLet’s go back to the coconut. Let’s assume that we have a male patient son and evidence, since it is only on the assumption that purported experts (based on the statistics associated with Brain Injury that males are more apt have the backing of reason and evidence that they rightfully gain authority. to be risk takers and more apt to become injured); and, that our patient susLife Care Plan preparation necessarily takes all of the above elements into tained a loss of consciousness. account. What we as an organization for example, in essence, have done is Where to start? I propose with a thorough analysis of the medical records ascribe to a bias that if one takes certain courses and passes an exam relative (educational and vocational records can provide additional information), the BRAIN INJURY PROFESSIONAL

first of which should be the paramedic run, to ascertain what transpired prior to the Life Care Planner’s involvement: what did the injured individual look like at the scene of the accident? What was the criterion (e.g., Glascow Coma Scale score) upon which his level of arousal was determined? Was there rapid response by emergency medical personnel? Was there a period of labored breathing/respiratory distress (in other words is there Hypoxic/Anoxic injury superimposed on the Traumatic Brain Injury)? Where did the impact occur (coup/contre-coup)? Were his pupils equal? reactive? How long was he unresponsive? Was he able to answer any questions as to what transpired or was he amnestic to the event? What observations can any witnesses provide? What was his level of arousal at the ER? What did his CT Scan/MRI look like? Did he have a skull fracture; a bleed? Was there any evidence of seizure? What was his hospital course like/comorbities/etc.? How long was it before he was oriented (period of amnesia)? What were his presenting symptoms? How long was he hospitalized? How did he respond to the injury? What was his Rancho Score; his functional capacity/ Functional Assessment Measures (FAM’s) at discharge/transfer from acute? Did he make progress in rehab? What was his Rancho Score; his FAM score upon discharge? What was his disposition? (home; SNF; etc.) Now, one is prepared to conduct their assessment. What to look for? First and foremost, if it is Brain Injury with which we are dealing, it is prudent to have again a “Collateral Source” with the individual to affirm or amend answers to given questions to ensure accuracy. My questioning typically begins with ascertaining the individual’s last memory prior to the accident; first memory subsequent to the accident; then, the existence of persistent amnesia ( short term memory dysfunction). I then utilize a “head to toe” assessment format, questioning the individual as follows and noting any difficulty in the same area premorbidly and/or with family history: Headaches? If yes: Location? Frequency? Intensity (scale of 1-10)? Duration? Accompanying visual changes? Antecendents? Relief? Any improvement since the time of the accident? Compare and contrast to any such difficulty prior to the accident? Any treatment for headaches premorbidly? Vision? Difficulties/Changes? (blurry; change is script; etc) Photosensitivity? Nystagmus? Visual Field Deficits? Corrective lenses? Prisms? Any difficulty prior to the accident? How long in corrective lenses/contacts? Frequency of, and most recent eval by opthamologist/optometrist? Ears? Ringing? Buzzing? Fullness? Decreased hearing? Any problem prior to? Dizziness? If yes, is it continuous? Is it intermittent? What brings it on? (position change; turning head; gazing upward) What relieves it? Balance/Coordination? Able to balance on each lower extremity? Heel to toe analysis? Able to walk on heels? Toes? Hold arms out with eyes closed (looking for drift) Any falls? Finger tap and foot tap. Finger to nose, examiners finger. Change in smell? Taste? Test with peanut butter/baby powder/coffee…with cultural variations taken into account. Food preference change? Difficulty with chew/swallow? Food? Liquids? Presence of jaw click? Problems prior to? Dental Health: now vs prior to? Frequency of visits? Breathing? Day? Exertion? Sleeping? Snoring? Prior hx? Any worse? GI problems? Indigestion? Reflux? Constipation? Bladder? Frequency? Urgency? Incontinence? Accidents? How often? Management? Any change from prior pattern? Any prior problems? Bowel? Frequency? Urgency? Incontinence? Accidents? How often? Management? Any change from prior pattern? Sexual Function? Any change from prior pattern? M/F dependent questions Male: Able to get an erection? Sustain an erection? Ejaculate? Female: Able to achieve arousal? Lubrication? Etc. Increased Tone/ Spasticity? Frequency? Intensity? Duration? Antecedent? Relief? Range of Motion: upper extremities/lower extremities Strength/Sensation: upper extremities/lower extremities Pain? Where? Level of intensity? (1-10) Frequency? Duration? Antecendent? Relief? Prior difficulty with pain? Mini Mental Exam: E.g., Difference btwn River and Lake; World spelled Backwards; last several Presidents; current concern around the world; serial 7’s; etc.

Of the “collateral” source, one would want to know if there are any discrepancies in the information provided; if there are concerns that have not been addressed; if there are such things as for example, changes in personality; an inability to stay on track; difficulty with organization, prioritization, judgment, problem solving, planning, sequencing, periods of the individual simply “starring into space”, loosing track in conversation, etc. Is it enough, then, to ask these questions each and every time one evaluates an individual for the purpose of Life Care Planning? I submit that it is not. One must additionally be able to understand/appreciate the significance of the answers vis-à-vis the pathophysiology known to be associated with, or 42 BRAIN INJURY PROFESSIONAL

at a minimum, suspected of Brain Injury; to be able to analyze and arrive at conclusion as the critical thinkers tell us. The main “differences” that I have noted in analyzing Life Care Plans constructed for the same individual by alternate Life Care Planners (assuming that the “side” the professional is on does not interfere in the decision making) is a lack of either sophistication (knowledge of the pathophysiology and what to look for) and/or adherence to a standard (a thorough assessment structure/ tool) in gathering the information in the first place; coupled with insufficient thoroughness (insufficient questioning of both the injured individual and/or collateral source; not addressing the pre-morbid health/functional status of the individual and considering appropriate offsets; etc.); and, the inability to arrive at sound conclusions in respect to the database/findings. There are certain assumptions that I entertain, based on my work with “like” cases. If, for example, there has been a skull fracture and/or a bleed, I will always look for signs and symptoms associated with Hydrocephalus. If there has been impact to the temporal lobe, I will always look for signs and symptoms of seizure. If an individual reports changes in smell and/or taste, I will note injury to the cranial nerves that regulate these functions and assume frontal lobe damage due to the proximity of these nerves to the frontal lobes. Although there are many other steps in the process of Life Care Planning, I will assume that they have been thoroughly discussed elsewhere and now move on to what I will attempt to depict as an illustration of the differences in a Life Care Plan prepared in respect to the same individual…in this instance, a 77 year old female. Case example: Female; DOB: 1926 DOI: 2004. Mechanism of injury: pedestrian hit by a slow moving bus in a pedestrian cross-walk History: Paramedic Run: only readable information: no loss of consciousness at the scene; GCS score of 14/15; repeated questioning and weak responses of extremities ER: Subjective: alert and oriented xs 4; PERRL; GCS score: 15/15; B/P: 197/100; O2 Sat on RA: 96%; pt c/o right head and left shoulder pain; 1 cm right occipital cephalohematoma, with 1 in scalp laceration; cranial nerves intact; sensory and motor findings WNL; moving all extremities; had full range of motion of neck; DTR’s normal; finger to nose function good; no functional deficits noted; noted to be hard of hearing otherwise physical exam noted to be normal Objective: Chest x-ray: WNL; Pelvic x-ray: mild degenerative changes; bony mineralization WNL; no evidence of fracture/dislocation. CT Scan of the head: interval blossoming of a left frontal temporal hemorrhagic contusion with interval appearance of hemorrhagic contusion in both frontal lobes as well as a small left parietal epidural hemorrhage (5mm); stable subarachnoid hemorrhage in the left sylvian fissure; stable extracranial soft tissue swelling in the right occipital region with no underlying fracture. No evidence of midline shift; hydrocephalus or herniation noted. CT of the Cervical spine showed calcific atherosclerosis; no fractures; no dislocations or other bony abnormailites; facet jolints appreared normal. Hospital Course: monitored overnight in ICU; transferred to the regular floor; hearing test revealed moderate to severe hearing loss in the right ear; no response in the left ear (patient reported she had been deaf in the left ear for some time); and, after being evaluated and cleared by neurology, neurosurgery; orthopaedics and ENT, discharged home with her daughter Day 2. At the time of discharge, patient was noted to have: good trunk and upper and lower extremity strength and intact coordination, without any focal deficits; fair to fair- for attention, problem solving, safety awareness, following simple commands, etc., and, had occasional difficulty with word finding; no complaints of pain; somewhat decreased mobility, secondary to weakness and endurance deficits, albeit with the ability to ambulate with hand-held assistance; the ability to complete most ADL’s with either “set up” and/or “minimal” assistance. Prior History: significant for Obesity; Diabetes and use of daily Glyburide; Hypertension; Allergic Rhinitis; Sinus Infections; Dizziness; Buzzing in her inner ears; a dx of Eustacian Tube Disease; Cholecystectomy; Abdominal Pain; Arthritic Pain in Knees/Hips and Upper Extremities, for which she used Tiger Balm and Aspercreme and Aleve; deaf in left ear for a long time; decreased hearing in her right ear; had cane, but no longer using; Social: lived independently; took the bus around town and did her own grocery shopping and housekeeping; cared for her disabled son, who lived with her; had lost a brother over the x-mas Holiday, then her estranged husband, with whom she had lived 30 years and kept in contact with subsequent to their separation, shortly after the accident Follow Up Visits/Diagnostic Testing: as of 4/1/04, gait noted to be

within normal limits, although pt reported not being able to walk “as fast”; 4/15/04 visit to her PCP for c/o abdominal pain, which predated the accident; headaches, with some improvement; dizziness, with some improvement; her daughter’s concern that she needed to be put into an assisted living facility and/or receive in home supportive services; her weight gain of 24 or so pounds; her repeat (5/10/04) audiological testing that revealed moderate sensorineural hearing loss in her right ear; severe to profound sensorineural hearing loss in her left ear; x-rays of her spine and a 10/12/04 visit with her PCP, resulting in a diagnosis of: Degenerative Disc Disease; Osteopenia; Fatigue; Hypertension; Depression. Recommendations, at her daughter’s insistence, for a Home Health Evaluation and her MD’s recommendation for a sleep evaluation, both of which she refused. 3/25/05 visit with her PCP, where it was noted that she weighed 234 pounds, a 6 pound loss (had fluctuated in this manner premorbidly); that she had some mild dyspnea on exertion; that her fasting blood sugars were in the 100 to 150 range (no HgA1c noted); that she was anxious when going out of the house into the community, but was able to do it nevertheless; that she was independent in the performance of her ADL’s; that she was able to again ride the bus and shop for groceries; that, on exam by case experts there were no neurological deficits noted; that she was observed to be able to stand up easily from a chair, as well as get on and off an examination table with little, if any, difficulty; and, that her gait was within normal limits. All available pre-morbid records were reviewed, as were all expert reports and expert, treater, plaintiff and family depositions. There were no abnormal neurological findings by either the plaintiff or the defense MD’s. There was ample indication from the pre-morbid records and the PCP’s testimony, that this woman had several significant health concerns prior to her March 2004 accident; and, that she would need treatment as a result. There was indication in one of the family member depositions that the family had been considering “placement” prior to the 2004 accident. The overall consensus amongst those who evaluated the patient in respect to this particular incident, was that her primary problem was depression; and, there was agreement that any true cognitive deficits could not be determined in the face of her untreated depression. The plaintiff ’s main complaints were what amounted to be occasional dizziness, minor depression, with easy fatiguability and hypersomina. She noted in psychiatric evaluation, that she “just wasn’t one of those depressed people and that when life is tough, one just needs to get on”. Although there was mention of some dizziness premorbidly, it did not seem to have been adequately evaluated (e.g., no neuro-otology evaluation, nor testing) subsequent to the accident. Interestingly, the plaintiff neuro-psychologist, who apparently just could not come to grips with the fact that this elderly lady, with a positive CT Scan had made such a remarkable recovery, literally “lobbied” the other plaintiff experts and convinced them that she had sustained a “severe”, rather than a “moderate” injury as the severity levels would more likely indicate; and, as such, noted she must need significant services. Additionally, the plaintiff Life Care Planner (an MD), apparently ignored most, if not all, of the pre-morbid health history and chose to include within the plaintiff Life Care Plan (see below) several items which I would classify as “would have been needed irrespective of the March 2004 incident”. Plaintiff Life Care Plan included: Physiatry 3xs/yr; Orthopedist 4-6xs over LE; Psychologist 24 sessions xs year; Family Counseling 15 sessions xs1 year; participation in an OP Rehab Program 3xs/wk for 16 weeks; and, an OP Pain Management Program 3xs/wk for 16 weeks, after completion of the OP Rehab Program; a TENS Unit, which would be replaced every three years; a recumbent stationary bike; a raised toilet seat and grab bars in the bathroom; a motorized scooter; a hearing aid for the right ear, to be replaced every five years; a single point cane; routine blood chemistries every 6 months; EMG/NCS 2x over the LE; x-rays of the spine 2 xs over LE; Attendant Care for 8 hours per day, 7 days per week; ER visits 2xs over LE; ambulance trips 2xs over LE; and, medications to treat the Arthritis at an annual cost of $1200 to $1400 per year. The Defense Life Care Plan included: a neuro-otology evaluation and diagnostic testing; neuropsychiatry intervention; 1x/week xs 3-4 weeks; then 1 x/3 months thereafter for 12 to 36 months; prescription of a stimulant/anti-depressant (e.g., Wellbutrin: 150mg to 450mg BID); case management: 12 hours/month for 3 months; then 4-8 hours/month for 12 to 36 months; both individual and family counseling; support group participation; speech therapy with a “pragmatic” focus three monts following initiation of psychiatric treatment; physical therapy with a vestibular (should neuro-otological testing confirm the need) and musculo/strengthening focus; a “life-Aert” Service; Meals-on-wheels and Housekeeper Services. It, for completeness, also included those items (i.e., Internal Medicine/Geritrician visits; Cardiologist visits; Dietician/Nutrition visits; Blood Chemistry; Lipid

Panel; Hemoglobin A1-C; EKG; a Hearing Aid and Batteries; a Weight Reduction Program; a Rehabilitation Fitness Program, with Pool Access; Safety Items; a Recumbent Stationary Bicycle; Non-Steroidal Anti-inflamatories; Diabeta; Vasotec) that would have been needed irrespective of the March 2004 accident, but did not assign a cost to the latter. The Defense Life Care Plan considered: the fact that the accident had indeed been a life altering event, especially in view of the loss of her family/loved ones in close proximity to the event; that, the patient was not likely as “sharp” as she had been pre-morbidly; and, that she was suffering from depression. In other words, the defense perspective utilized all of the key elements of critical thinking…criterion (facts of the case); evidence (evaluation findings); bias and certain assumptions (the fact that the aging process itself accounts for many of the symptoms with which we were dealing on this case, as borne out by research (e.g., Osteoarthritis and Aging; Signs and Symptoms Associated with Eustacian Tube Dysfunction; ER’s Getting More Crowded and the fact that the elderly account for 60 out of every 100 visits in persons over age 75; Falls and the older Person; Age Related Hearing Loss; etc.); analysis (history; evaluation findings; patient’s own report of functionality; etc.); conclusions (a need to rule out any physical constraints to progress, be they pre-morbid or not (e.g., the ongoing complaints of dizziness and potential that the inner ear dysfunction may be in some way associated with head injury); then, a focus alleviating the depression, albeit likely both pre and post morbid; and, lastly, providing a modicum of therapeutic intervention to strengthen compensatory strategies and promote the patient’s well being within the environment she preferred….her own home). Why the difference? I return to the Glossary of Critical Thinking for an explanation. Because the plaintiff experts on this case did not utilize the tools of critical thinking; and, instead leaned over backwards to justify the position they assumed that was based upon what they had in the past experienced (e.g., most folks this age, with a bleed of this nature documented on CT, etc. do not recover to the extent that we saw in this case), versus what the case facts actually presented. They, in essence, negated the information that did not serve their interests. The Glossary tells us that logical and moral consistency are fundamental values of fair-minded critical thinking; that thinking can be oriented or structured with different issues or purposes in view; that thinking varies in accordance with purpose and issue, but that Critical Thinkers, learn to discipline their thinking to take into account the nature of the issue or domain. We see here a clear example of what the Glossary tells us is a common form of uncritical thinking, which involves the distortion of facts or experience in order to “preserve” a preconceived notion or theory. It goes on to note that this is the ultimate of egocentricity: a tendency to view everything in relationship to oneself; to confuse immediate perception (how things seem) with reality; and, that egocentricity is one of the fundamental impediments to critical thinking. The explanation for the differences should now be obvious. Suffice it to say, that in Life Care Planning, one’s point of view must be driven by the premise that facts should be assessed for their accuracy, completeness and relevance to the issue. Finally, a quote from William Graham Sumner, Folways, 1906: The critical habit of thought, if usual in society, will pervade all its mores, because it is a way of taking up the problems of life. Men educated in it cannot be stampeded by stump orators ... They are slow to believe. They can hold things as possible or probable in all degrees, without certainty and without pain. They can wait for evidence and weigh evidence, uninfluenced by the emphasis or confidence with which assertions are made on one side or the other. They can resist appeals to their dearest prejudices and all kinds of cajolery. Education in the critical faculty is the only education of which it can be truly said that it makes good citizens.

About The Author

Ms. Roughan has extensive health care industry experience in critical care and rehabilitation nursing, as well as nursing education and supervision. She was instrumental in the development and implementation of one of the original case management programs in the US, on behalf of the Equitable Life Assurance Society of America in their Group Health Division. Her prior experience has provided the basis for a sound pathophysiological basis upon which her current practice in case management and Life Care Planning is built. She has provided expert testimony on behalf of both the plaintiff/applicant and defense bar; and, has been recognized for her contribution to and provision of expert testimony on well know cases such as the “Brockovich” (i.e., PG&E) matter. BRAIN INJURY PROFESSIONAL

non-profit news BRAIN INJURY ASSOCIATION OF AMERICA Many professionals know the mission of the Brain Injury Association of America is to create a future through brain injury prevention, research, education and advocacy. But nearly every day someone asks, “What does BIAA do?” We are pleased to update NABIS members on our activities. In March, BIAA circulated 10,000 Brain Injury Awareness Month kits with funding from the Centers for Disease Control and Prevention and support from many other federal agencies and volunteers. We hope NABIS members will use these materials to spread the word about brain injury throughout the year. We’re working to elevate the National Center for Medical Rehabilitation and Research within the NIH. Meetings with key officials hold promise for modification of protocols that inhibit rehabilitation research in clinical settings. In the meantime, BIAA continues to disseminate findings from three National Institutes on Disability Rehabilitation and Research initiatives—TBI Model Systems, Assistive Technology, and Self-Employment. NABIS leaders are among the faculty at our Caregivers’ Conference in June in Washington, D.C. Planning is underway for BIAA’s 2nd Business Practice College, the only forum focusing on the “bottom line” in brain injury. In July, our David Strauss Memorial Lecture Series will be offered in a webcast format, and we’re delighted to co-sponsor the UCLA Neurotrauma Conference in August. BIAA has a new website at www.biausa.org that’s chock-full of information and much easier to navigate. We are grateful to our Corporate Sponsors for making the new site possible. The next edition of TBI Challenge!, is a special celebration of the TBI Act’s 10th Anniversary. We are lobbying Congress for $30 million to fully fund this legislation and actively supporting funding increases for the TBI Model Systems and the Defense and Veterans Brain Injury Center programs. BIAA is also working with a variety of coalitions to increase funding for services and research, expand federal programs, protect the rights of individuals with brain injury and family members and educate Members of Congress. Our issues run the gamut from health and disability to housing, education and transportation. We invite NABIS members to join our Legislative Action Center at www.biausa.org.

INTERNATIONAL BRAIN INJURY ASSOCIATION IBIA had an excellent World Congress in Melbourne, Australia in May of last year due to the efforts of Australian organizers Drs. Ponsford, Olver and Burke. IBIA would like to thank the outgoing President, Claudio Perino, M.D., and Chairperson, Robert Voogt, Ph.D. for their service to the organization over their term. Effective as of the May meeting, Nathan Zasler, MD 44 BRAIN INJURY PROFESSIONAL

has taken the helm as Chairperson, with Dr. Donald Stein, as President, Dr. Jose Leon Carrion as secretary, and Bruce Stern, Esq. as treasurer. Perhaps most significantly, we are delighted to announce a major reduction in the cost of membership in IBIA. As of 2006, the new rate for full membership is $250.00 per year. As in years past, this fee includes a subscription to our official journal Brain Injury, published by Taylor and Francis. Professionals should note that this represents a significant savings off of the regular subscription price to the journal offered by the publisher. A membership form can be downloaded from our website, www.internationalbrain.org As an additional benefit of membership, we are now publishing our quarterly publication, the International NeuroTrauma Letter (NTL) in an electronic format. NTL contains original articles, book, technology and product reviews, conference listings, as well as, information on the upcoming IBIA meetings and educational events. The NTL also serves as a forum for dissemination regarding regional brain injury organization’s including NABIS, EBIS and LABIC. A unique feature of NTL is the “Ask the Doctor” column, in which IBIA members are encouraged to submit questions, no matter how basic or esoteric, with responses published in subsequent issues. IBIA has been involved with efforts to coordinate educational events with the World Federation of Neurological Rehabilitation (WFNR) and has also supported and /or participated in numerous recent meetings including a Brain Injury Awareness day for the US Congress and the Conemaugh International Symposium, which resulted in the Conemaugh Report to the US Congress entitled “Toward Successful Recovery from Traumatic Brain injury: Improving Outcomes and The Mohonk Workgroup on Disorders of Consciousness Meeting spearheaded by Dr. George Zitnay of NBIRTT (National Brain Injury Research, Treatment and Training Foundation. Finally, work is underway on the planning for the Seventh World Congress on Brain Injury which is scheduled to be held in 2007. Please visit www.internationalbrain.org for Congress and other IBIA news updates.

NATIONAL BRAIN INJURY RESEARCH TREATMENT & TRAINING FOUNDATION NBIRTT is a national, not-for-profit foundation organized to provide support for research, treatment and training in brain injury through individual research grants, contracts and small business grants. The primary goal of the Foundation is to find a “cure” for brain injury. The Foundation encourages professionals to engage in cutting-edge research treatment and training involving: • Finding a cure for brain injury • Improvement of the quality of life for persons with acquired brain injury and their families

non-profit news • Development of model-effective real world treatment and rehabilitation • Establishment of small businesses willing to develop products to assist persons with brain injury and their families • Provision of first-class training for professionals and family members in the latest technology, evidence-based medical practice guidelines and treatment methodology through seminars, conferences, publications and telemedicine. NBIRTT is very active in advocacy work in our nation’s Capitol; working with the Congressional Brain Injury Task Force and the Brain Injury Association of America on matters of public policy which affect the 5.3 million Americans living with the effects of a brain injury as well as the Defense Veteran’s Head Injury Program, which serves the men and women in the Armed Services who sustain brain injuries while in active duty. NBIRTT is also active in hosting and facilitating national and international symposia. In October of 2005, NBIRTT, along with the Conemaugh Health System, the John P. Neuroscience and Pain Institute and many others hosted the Conemaugh International Symposium: Toward Successful Recovery from Traumatic Brain Injury: Improving Outcomes in Johnstown, PA. For more information visit, www.nbirtt.org.

NATIONAL ASSOCIATION OF STATE HEAD INJURY ADMINISTRATORS Many individuals with brain injury turn to the State for services and supports as they learn to live with their brain injury. Their needs are likely to cross the traditional boundaries of State programs and agencies thus challenging the ability of the State to provide the appropriate services and supports for the individual with a brain injury and their family to flourish. The mission of the National Association of State Head Injury Administrators (NASHIA) is to try to make sense of this often puzzling array of services and supports in a way that best fits the individualized needs of each individual with a brain injury. NASHIA is currently focused on preserving one successful way our members and States have been able to use to improve the provision of services and supports. The United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Federal Traumatic Brain Injury (TBI) Program funded through the Traumatic Brain Injury Act has been eliminated in the President’s 2007 budget proposal. In a recent study conducted for the TBI Program by the Institute of Medicine of the National Academies (IOM), the IOM observed that the States have used small grants to create sustainable infrastructure and improved capacity for comprehensive, coordinated and integrated service systems. The report concludes that the State TBI programs are at a critical stage and need continued federal support to effectively meet the needs of individuals with TBI and their families. NASHIA

calls on everyone who is interested in improving services and supports for individuals with brain injury and their families to contact their Congressional representatives to fully fund the TBI Act. We believe this will mean $21 million for the Federal TBI Program ($15 million for State grants and $6 million for the Protection Advocacy grants) and $9 million for the Centers for Disease Control and Prevention. Check out our website at www.nashia.org to see the latest information on this effort and to familiarize yourself with the full array of NASHIA products and services.

NORTH AMERICAN BRAIN INJURY SOCIETY Planning is well underway for the Brain Injury Conference of the Americas, scheduled for September 14-16, 2006, at the Eden Roc Resort in Miami. Over forty speakers from Canada, Latin America and the USA are scheduled to present on the very latest developments in brain injury treatment and care over a three-day period. In addition to the speaker sessions we are especially pleased to be introducing several unique panel workshops that will cover Blast Injuries, Women’s Issues, Multicultural Issues and Neuroimaging. Also new this year we have expanded our Call for Abstracts to include both poster and oral presentations. NABIS values abstracts that present current and best practices, including information that compliments the Conference’s topic tracks (Long Term Living, Medical/Science, Concussion/Mild TBI and Legal Issues) as well as innovative approaches to brain injury assessment, treatment, intervention and rehabilitation. Also encouraged are abstracts that deal with international and crosscultural approaches to TBI rehabilitation. Be sure to note the deadline for submitting an abstract is June 21st. The NABIS conference is also an excellent opportunity to network and promote brain injury products and services – last years’ exhibit opportunities sold-out very quickly and companies interested in exhibiting are encouraged to reserve their space as soon as possible. To download a sponsorship prospectus, visit www.nabis.org. We are pleased to announce the formation of the second state affiliate of the Society, the North Dakota Brain Injury Society (NDBIS). NDBIS has been established to promote professional awareness, understanding and dissemination of information about brain injury through education and collaborative opportunities that advance the field of brain injury in North Dakota. NDBIS joins the Texas Brain Injury Society, which became the first affiliate of NABIS in May of last year. NDBIS will be chaired by Mariusz Ziejewski, PhD, and Rodney Swenson, PhD, ABPN will serve as President. Dr. Ziejewski serves on the International Brain Injury Association’s Board of Governors and the Board of Directors of the North American Brain Injury Society. To learn more about our work at NABIS, please visit www. nabis.org. BRAIN INJURY PROFESSIONAL

new and noteworthy March was National Brain Injury Awareness Month and the Congressional Brain Injury Task Force, chaired by Rep. Bill Pascrell of New Jersey and Rep. Todd Platts of Pennsylvania, organized Brain Injury Awareness day on Capitol Hill. This event honored persons with brain injury, their families and the vast community of caregivers, medical professionals, scientists, and advocates. The Task Force serves as a clearinghouse of information for Congress and the public, promotes full funding for the TBI Act and other brain injury research programs, and provides guidance to federal agencies on policies and proposed rulemakings. For more information on the Task Force visit Congressman Pascrell’s website at www.pascrell.house.gov. An Ontario jury has awarded $13 million in damages and interest in the case of a two year old boy who fell from a fifth story apartment window. This is the largest amount awarded by a Canadian jury for a brain injury case. About 125 friends of Bryn Mawr Rehab Hospital of Malver, PA, gathered on March 22 to celebrate the beginning of construction to expand and renovate the hospital’s brain injury unit. The $2.9-million project is expected to be completed early next year. A $1-million fundraising campaign has already raised $625,000. Mentor ABI has launched a new Post-Secondary Program for individuals who want to earn a college degree or learn a new technical trade. The Post-Secondary Program at the Center for Comprehensive Services (CCS) is designed to meet the needs of high school graduates who may benefit from further development of academic, social and daily independent living skills. The new program 46 BRAIN INJURY PROFESSIONAL

is located in the college town of Carbondale, Illinois, home of Southern Illinois University and near John A. Logan Community College. Several technical programs, such as heating and air conditioning, welding and cosmetology, are also offered throughout the Southern Illinois area. Visit www. siuc.edu for more information. Craig Hospital of Englewood, CO, has announced that Donald J. Gerber, PsyD and James Berry, PhD have received Diplomate status in Rehabilitation Psychology by the American Board of Professional Psychology. There are only 115 Diplomates in Rehabilitation Psychology in North America, and Craig Hospital has three of the five total ABRP Diplomates in the Rocky Mountain Region. Dr Gerber has worked at Craig a total of 25 years, spanning back to 1979, and Dr. Berry has been at Craig since 1991. The Brain Trauma Foundation has announced that the 3rd edition of the Guidelines for the Surgical Management of Traumatic Brain injury will become available in July 2006. In the meantime, you may view the 2nd edition on this website by visiting BTF’s website www.braintrauma.org. The Guidelines were approved by the Congress of Neurosurgeons and were published as a supplement to Neurosurgery March 2006. The 2006 Robert L. Moody Prize for Distinguished Initiatives in Brain Injury Research and Rehabilitation was recently awarded to Dr. Barbara Wilson. Dr. Wilson is the director of research at the Oliver Zangwill Centre for Neuropsychological Rehabilitation in the United Kingdom. The Moody Prize is given to honor and recognize individuals or a team of individuals who have made significant contributions in applied brain injury research and rehabilitation.

The Economic Cost of Brain Injury According to new findings just released by the Centers for Disease Control and Prevention (CDC), direct medical costs and indirect costs such as lost productivity of traumatic brain injury (TBI) totaled an estimated $60 billion in the United States in 2000 alone. The new data and findings were released in the

book The Incidence and Economic Burden of Injuries in the United States, by scientists from the CDC, as wells as scientific research contractors at RTI International and the Pacific Institute for Research and Evaluation. This groundbreaking book, published by Oxford University Press, examines the lifetime costs associated with the injuries that occur in just one year. In 2000, the 50 million injuries that required medical treatment will ultimately cost $406 billion. These total costs, for both fatal and nonfatal injuries, include estimates of $80.2 billion in medical care costs and $326 billion in productivity losses, which include lost wages and the accompanying fringe benefits, as well as the lost ability to perform normal household responsibilities. For more information visit www. www.us.oup.com/us.

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