The Changing Landscape of Holistic Brain Injury Rehabilitation Lance E. Trexler, PhD, HSPP, FACRM
In the Beginning The need for specialized rehabilitation strategies for those with acquired brain injury became particularly apparent in the United States in the 1980’s. Traditional rehabilitation paradigms did not address the cognitive and neurobehavioral impairments associated with acquired brain injury, or their psychological consequences. Holistic brain injury rehabilitation programs included group and individual psychotherapy, cognitive rehabilitation, family education and therapy, all in context of a therapeutic milieu that was typically structured as a day treatment program.1 Ben-Yishay2 described four stages of holistic rehabilitation, including 1) awareness and understanding of one’s own impairments and commitment to rehabilitation goals, 2) becoming malleable to treatment, 3) learning new metacognitive strategies to compensate for the impairments and integrating them into real world environments, and 4) acceptance and finding a new meaning in life. Many of these programs also included physical, occupational, and speech therapies as appropriate. The holistic model was structured as a day treatment program, four to five days a week, typically lasting for six to nine months with follow-up thereafter as needed. The most recent evidence-based review demonstrated that holistic neuropsychologically-oriented rehabilitation programs resulted in significant improvements in societal participation, vocational outcome, short and long term functional skills, and psychosocial adaptation.3 The findings also suggested that these programs also reduced societal cost and reduced caregiver burden. Based on the strength of the evidence, holistic neuropsychological rehabilitation programs were determined to be a practice standard for people with traumatic brain injury.
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However, even by 2000, reviews of the evidence demonstrated that comprehensive-holistic programs resulted in significant reductions in the level of disability, and these programs were therefore considered to a Practice Guideline .4
And then Catastrophe Despite the fact that brain injury professionals created new programs and provided abundant scientific evidence of their positive impact in twenty years, “managed” care decimated holistic brain injury rehabilitation beginning in the early 1990’s and very few programs now remain throughout the United States. The charges for holistic programs were typically structured as a daily or weekly rate, and in some programs, a total charge for a six or nine-month program. The insurance companies began to require individual charges for each discipline-specific service and limit the total number of sessions per discipline. However, many holistic programs included services for which either no CPT code existed or was very poorly reimbursed, like family education and family therapy without the patient present, group therapy, community-based therapeutic experiences that involved travel time and expense, vocational trials, and team conferences to plan and revise rehabilitation goals and strategies. These changes also included restrictions on how many total therapy services could be provided in a day. As a consequence, these changes served to deconstruct programs that were specifically designed to meet the needs of people with acquired brain damage and their families with a “holistic” approach that addressed the inter-related cognitive, neurobehavioral, and psychological challenges that negatively affected independent living, return to work or school, and psychosocial adjustment.
