Care considerations for patients with traumatic brain injuries

Courtesy of the prevalence of traumatic brain injuries (TBI) in the military and across sports, this diagnosis has hit the mainstream. The most minor hit on the head can cause clients to have headaches, dizziness, trouble concentrating, memory problems, and irritability. Escalating numbers, movies, and news stories inform clients and family members of the realities faced by those who suffer TBIs. Case managers are challenged by a vast range of circumstances:

• Reconciling conflicting prognoses with uncertain discharge planning needs
• Engaging in high levels of advocacy with payers to obtain coverage for necessary services and accommodations
• Determining complex physical and behavioral health needs
• Managing family uncertainty around prognosis
• Client frustration
• Ensuring competency
• Promoting autonomy
• Safety concerns

Clients who have suffered a traumatic brain injury are complex on many levels. For practitioners, the severity and extent of the injury are often unclear, with prognosis also unknown. Having case managed for the brain injury unit of an acute rehabilitation program, I had countless dialogues with the physiatrists I worked with. A frequent topic of conversation involved the intricate wiring of the brain and the uncertainty of how these connections were interrupted by each injury. That intricacy could lead to recovery surprises as readily as heartbreak. The traditional tools used to assess the extent of injury (e.g., MRI, CT scan) could fool practitioners, at times identifying no evident physiological changes. When injury is finally confirmed, family members are often told prognostic extremes, from a full return to baseline to a lack of optimism for the potential of any meaningful recovery.

Other factors come into play, such as the determination of competence. There are adjustments for all involved, whether child, adolescent, or adult. If the client is a child or adolescent, what schooling needs are required, and for how long? How is the injury explained and understood by siblings? If the client is an adult at the time of injury, there are equally unique challenges. Consider the successful businessman who suffered an aneurysm, or the young mother who had a stroke after childbirth. Although both clients recover from their acute events, the longer-term questions prevail. Will either client be able to be responsible for their own care and decision-making? The businessman, who is recently divorced, may need a guardian unless his ex-wife or oldest son steps up. The mother may be unable to independently care for her new baby. Is return to work of any type realistic? Will the person be able to be retrained? Is the current status as good as it gets?

The client may look physically fine, which can be deceptive to all. The boss comes to visit and doesn’t understand why the client can’t return to work. A family may be in denial that anything is wrong until something happens, like the post-TBI parent being left home alone and forgetting to close the front door, allowing a young child to walk outside unescorted. As realization sets in that occupational and behavioral health, physical, and often social changes are involved, a case manager can get an endless array of questions, if not cries for help.

Concerns about the length, extent, and focus of treatment manifest. Can the client return directly home from the inpatient rehabilitation program? It is common for clients with a TBI to not warrant hospitalization and be discharged home from the emergency department with a "clean or negative" MRI. But 24 or 48 hours later, symptoms may appear, like dizziness, nausea, light sensitivity, or extreme headaches. I remember one client who fell and hit her head at work. Although she presented as initially fine, three days post-injury, the client developed tremors from brain swelling, needed a cane to ambulate, and became forgetful. Despite the deterioration, the client did not meet criteria for inpatient hospitalization. Ultimately, arrangements were made for the client to start a brain injury outpatient program, though not without major concern and emotional angst from family and friends.

One challenge with more severe TBIs may emerge from the need for care or extended therapy beyond what the insurance company will pay for. Families of any client do not usually understand why their loved one can’t stay at acute rehab or in treatment until "cured." For those who suffered a TBI, this factor is even more significant. Although the structure and compensatory strategies offered by the treatment are beneficial, at some point, a cap is met and therapies must end. Clients often plateau, and all involved become frustrated. If at this point the client needs extended supervision to ensure safety, a family may have to face the tough decision of considering nursing home placement. Finding a facility able to address the cognitive impairments of a person with a TBI is tough at best. Arranging payment can be tantamount to climbing Mount Everest. A considerable financial commitment or long-term Medicaid application may be required, with further challenges to obtain an appropriate bed. The acute event suddenly feels endless, with the client’s family in constant crisis.

For more information, see The Essential Guide to Interprofessional Ethics in Healthcare Case Management.