Welcome to today’s webinar for ACL Grantees!...Before we begin today’s webinar…a few housekeeping items: First, we would like to Thank you for attending! Please double check

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RHI-EAGLE HIGHLANDS INPATIENT AND

OUTPATIENT SERVICES

4141 Shore Drive

Indianapolis, IN 46254

RHI-NORTHWEST BRAIN INJURY CENTER

9531 Valparaiso Court


RHI-CARMEL OUTPATIENT SERVICES

12425 Old Meridian Street, Suite B2

Carmel, IN 46032

RHI is a community collaboration between

Indiana University Health and St. Vincent Health

317-329-2000 | rhin.com

Resource Facilitation Webinar Series

Presentation to ACL Grantees

Today’s Topic: Resource Facilitation as a Model to

Manage TBI as a Chronic Condition

Today’s Speakers: Flora Hammond, MD

Nila Covalt Professor and Chair,

Physical Medicine and Rehabilitation,

Indiana University School of Medicine

Chief of Medical Affairs,

Rehabilitation Hospital of Indiana

Lance Trexler, PhD, HSPP, FACRM

Executive Director, Brain Injury

Rehabilitation Research and Program

Development, Rehabilitation Hospital of Indiana

Clinical Assistant Professor,

Physical Medicine and Rehabilitation,

Indiana University School of Medicine

March 31, 2020| Welcome ACL Mentor State Indiana’s Webinar Series on

Resource Facilitation

Overview:

It has been recently recognized that recovery and long term

stability following TBI is variable and inconsistent, within and

between people with TBI and some people with TBI will have a

chronic condition as a consequence. There is currently no health

care model to manage TBI as a chronic condition. There is

however a number of research findings for Resource Facilitation

that may suggest that this intervention could serve as an initial

model.

Learning objectives for this webinar include:

1) Participants will be able to describe the results of long-term

follow-up studies with respect to recovery and stability.

2) Participants will be able to identify three characteristics of

Resource Facilitation.

3) Participants will be able to state three different types of

outcomes that are associated with Resource Facilitation.

ACL Mentor State Webinar Series on Resource Facilitation | Indiana | RF as a Model to Manage TBI as a Chronic Condition | Mar 31 2020

Flora Hammond, MDProfessor & Chair, PM&R

Indiana University SOM


Indianapolis, IN

Managing Brain Injury as a Chronic

Condition


NIDILRR TBI Model Systems National Database

• 30 years with >17,000 database participants

• Admitted to acute care within 72 hours of TBI & received inpatient rehabilitation

• > 16 years of age

• Complicated mild, moderate or severe TBI• neuroimaging abnormality, PTA, LOC, or ED GCS score


5-year Rehabilitation OutcomesCorrigan JD, Cuthbert JP, Harrison-Felix C, Whiteneck GG, Bell JM, Miller AC, Coronado VG, Pretz CR. J Head Trauma Rehabil 2014:29(6):E1-9.

• TBI Model Systems participants

• Received rehabilitation October 2001 - Dec 2007.

• Weighted for national population characteristics • age, sex, race, race/ethnicity, marital status, primary insurance, FIM

motor & cognitive score at rehab admit, and RLOS

• Status 5 years post-TBI:• 84% known outcome

• 10% lost to follow-up

• 6% withdrew/refused/unknown

• 39% declined (GOS-E) Y1/2 Y5

• 22% dead by Y5

From Y1 or 2 to 5:

2 in 10 die

3 in 10 deteriorate

Death associated with older age

Decline not associated with age


13% 11% 9% 10%19% 17% 16% 19%

48% 45% 42% 39%

12% 14%13% 8%

9% 13% 21% 24%

0%

20%

40%

60%

80%

100%

Year 2 vs.Year 1

(N=4,986)

Year 5 vs.Year 2

(N=2,867)

Year 10 vs.Year 5

(N=796)

Year 15 vs.Year 10(N=194)

% 2 categ. Declined % 1 categ. Declined % no change

Change in Function Over Time: Glasgow Outcome Scale (GOS-E)

Corrigan JD & Hammond FM Arch Phys Med Rehabil 2013

BI is a dynamic

condition: Significant

change years after TBI

No Change: - 39 - 48%

Improvement: - 24 - 31%

Decline: - 20 - 34%


• Cardiovascular

• Unintentional

• Septicemia

• Cancer

• Pneumonia; Other resp

• Digestive

• Homicide

• Suicide

• Seizure

• Seizure (37x)

• Septicemia (12x)

• Pneumonia & aspiration PNA (4x)

• Other respiratory (3x)

• Digestive (3x)

• External (3x)

• Unintentional (3x)• Accidental poisoning (4%)(11x)

• Opioids

• Homicide (3x)

• Suicide (1x)

Most Frequent Causes > Expected for General Population

• 7-year reduction in life expectancy

• Causes of death vary over time post-injury

• Association with older age & > disability at rehab discharge

Premature Mortality with Moderate-Severe TBIHarrison- Felix C, Whiteneck G, DeVivo MJ, Hammond FM, Jha A: JHTR 2006


• Among those >50: DM, Cholesterol, HTN, OA• Among those < 50 years: panic attacks (3x)• No age differences for back pain, fractures, sleep disorders,

depression, anxiety

Ten Most Prevalent Comorbidities

10 years after Moderate-Severe TBIHammond FM, Corrigan JD, Ketchum JM, Malec JF, Dams-O’Connor K, Hart T, Novack TA, Bogner J, Dahdah MN, Whiteneck GC : JHTR 2019


Comorbidities & Consequences

• Pain• Substance use• Social isolation• Incarceration• Reinjury• Psychiatric disorders • Neuroendocrine

dysfunction• Seizure• Stroke• Dementia• Higher rates diabetes,

hypertension, myocardial infarction, cerebrovascular disease, peripheral vascular disease, chronic pulmonary disease, & renal disease

• Premature mortality


Primary Medical Care & Brain InjuryHarrington AL, Hirsch MA, Hammond FM, et al. Am J PMR 2009;88:852

• People with BI less likely to have PCP

• Reasons no PCP: • no transportation

• $

• can’t find

• would not understand disability

• “don’t need one”

• 36% had to teach their PCP about disability

• 3% physical access issues


Chronic Brain Injury2012 Galveston Brain Injury Conference

“Injury to the brain can evolve into a

lifelong health condition termed

chronic brain injury (CBI). CBI impairs

the brain and other organ systems

and may persist or progress over an

individual’s life span. CBI must be

identified & proactively managed as a

lifelong condition to improve health,

independent function and

participation in society.”



Chronic Disease Management Programs

CommunityHealth Systems

Delivery System DesignCreate

Supportive Environment

Build Public Policy &

Resources

Provide Self-Management

Support

Decision Support

Clinical Information

Systems


Target the right people with the right care & intensity

High risk, complex needs: intensive professional & case management

Some risk, increased need: shared care with self, close others, & professionals

Low risk: (70-80% of chronic disease population); supported self-management

Problem-driven, Risk-stratified Care


• Paradigm shift to treat BI as a chronic condition to enhance care & access to optimize outcomes

• Design & test models of care

• Indiana Resource Facilitation

• Tailored to individual needs, problems, and risks

Summary

Flora Hammond, MD

[email protected]


mailto:[email protected]

Survivor Perspective

"I think I may need it to have periodic evaluations to determine my level of capacity on a regular basis. Some things have improved and some symptoms have worsened and others are just now beginning to surface. I think that establishing a history of capacity would give a better picture of services needed and other medical tests that may need to be done. This would provide a full range of services that would better serve your clientele."


Evidence for Resource Facilitation to Manage Outcomes following Chronic TBI


Resource Facilitation Defined

• Individualized assessment

• Provide brain injury specific education and promote awareness of resources

• Proactive navigation to community-based supports, resources and services

• Remove instrumental barriers (e.g., housing) as well as brain injury-specific barriers (e.g., memory impairment) to successful community re-integration and return to work.


Resource Facilitation to Manage TBI as A Chronic Condition


Indiana Resource Facilitation Research Findings for Vocational Outcomes

• RCT 1: 64% return to work rate after 9 months of RF versus 36% for controls (P<.0001)

• RCT 2: RF group return to work/school significantly earlier and more often than controls (P<.027), and

Group assignment was a significant predictor of outcome (P=.027) and the RF group was found to be 7 times more likely to return to work

• Trexler, L.E. & Parrott, D.R (2018). Models of Brain Injury Vocational Rehabilitation: The Evidence for Resource

Facilitation from Efficacy to Effectiveness. Journal of Vocational Rehabilitation, 49(2), 195-203.

• Trexler, LE, Parrott, DR, & Malec, JF (2016). Replication of a Prospective Randomized Controlled Trial for Resource

Facilitation to Improve Return to Work after Brain Injury. Archives of Physical Medicine and Rehabilitation, 97(2), 204-210.

• Trexler, LE, Trexler, LC, Malec, JF, Klyce, D., & Parrott, D. (2010). Prospective randomized controlled trial of resource

facilitation on community participation and vocational outcome following brain injury. Journal of Head Trauma

Rehabilitation, 25(6), 440-446.


Resource Facilitation and Return to Work

• Prospective Clinical Cohort 1 (n=69):• Subjects referred from Indiana Vocational Rehabilitation

• 9.28 years post-injury

• 67% return to work rate after 9 months of Resource Facilitation versus 18%

• Prospective Clinical Cohort 2 (n=141):• Subjects referred from Indiana Vocational Rehabilitation

• 10.10 years post-injury

• 70% return to work rate after 11.6 months of Resource Facilitation versus 18%

Trexler LE and Parrott, D.R (in press). Models of Brain Injury Vocational Rehabilitation: The Evidence for Resource Facilitation from Efficacy to Effectiveness.

Journal of Vocational Rehabilitation.


CENTER FOR BUSINESS AND ECONOMIC RESEARCH Phone: 765-285-5926

MILLER COLLEGE OF BUSINESS Fax: 765-285-8024

February 21, 2017

Economic Impact of Resource

Facilitation:

Workforce Re-entry Following

Traumatic Brain Injury Brandon Patterson, Graduate Research Assistant

Srikant Devaraj, Ph.D., Research Economist and Research Assistant Professor

Michael J. Hicks, Ph.D., George & Frances Ball Distinguished Professor of

Economics, Director of Center for Business and Economic Research

Annual Aggregate Lifetime Economic Impact of Resource Facilitation

• Wages and benefits = $249.1 million

• Revenue from taxes = $30.97 million

• Savings to SSDI/private disability = $80.1 million

• SNAP = $6.6 million

• Total = $366.77 million/year


Other Non-Vocational Research Findings

for Resource Facilitation


Activities of Daily Living Scale

• Self Care Activities

• Household Care

• Employment and Recreation

• Shopping and Money Management

• Travel

• Communication

• Total

Results demonstrated a statistically

significant decrease in the reported

amount of assistance required to

complete activities of daily living

after RF (t=5.35, p=.000).

•Johnson, N., Barion, A., Rademaker, A., Rehkemper, G., & Weintraub, S. (2004). The

Activities of Daily Living Questionnaire: a validation study in patients with dementia.

Alzheimer disease & associated disorders, 18(4), 223-230.


Mayo-Portland Adaptability Inventory

MPAI-4 results show a significant (t=4. 07, p=.000). decline in level of disability across all subscales:

• abilities (e.g., mobility, memory),

• adjustment (e.g., depression social interaction), and

• participation (e.g., managing money, transportation) after RF


Survey of Unmet Needs and Service Use

Heinemann, A.W. et al. (2002). Measuring unmet needs and services among persons with traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 83, 2052-1059

• Developed specifically for brain injury

• Variety of instrumental and service needs

• Addresses both what they are receiving and perceived needs


Survey of Unmet Needs

• Number of services used declined significantly from baseline to discharge (t=2.83, p=.005).

• Desired services declined significantly from baseline to discharge (t=13.53, p=.000).

• Examples of needs that were met through RF:

• controlling alcohol and/or drug use,

• increasing independence in eating, dressing, and bathing, and

• finding housing that is affordable and accessible.


TBI, Resource Facilitation and Re-Arrest: New Findings

Recidivism for Offenders:

• With TBI = 24.2%

• Without TBI = 17.7%

RF Findings:

• 195 offenders with TBI, 31 of whom got RF.

• 10% re-offended who got RF.

• 25.6% of the control group re-offended.

• Offenders with TBI who did not get RF were found to have a risk for re-offending of over two and a half times greater than those who got RF (RR =2.64)

• RF can cut the risk of re-offending by 60% (25.6% vs 10%)

Trexler LE & Parrott DR (in preparation). Resource Facilitation and

the Prevention of Re-Incarceration in People with TBI.

Z=2.05,

p=0.02

Z=1.93,

p=0.027


Conclusions

• Resource Facilitation significantly improves return to

work and school for acute and chronic TBI

• These effects result in a significant economic benefit

• Preliminary data suggests that Resource Facilitation may

• Reduce level of disability in chronic TBI

• Reduce services used and desired services

• Reduce recidivism


Utilization of BEAM in a Randomized

Controlled Trial of Resource Facilitation


BEAM/MyBRAIN

• Clinical Individual and Cohort Purpose:• Surveillance

• Assessment and Re-Assessment

• Risk Stratification

• Intensity and Type of Resource Facilitation Follow-up

• Self-Management Training

• Use data for research on • Predictors of recovery – stability – decline

• Effectiveness of treatment


BEAM/MyBrain Risk Assessment: Pre-Injury Variables

Domain MeasureReassessment

Frequency

Monthly Surveillance

measure

Criteria for High or Low Risk

Risk RatingLow = 1 High=2

Substance Abuse PROMIS Severity of SAat Baseline 2

(RA)T < 59 T > 60

CriminalityMinnesota House Research Dept, 2007

at RF Intake No criminal history

misdemeanor, gross misdemeanor, or felony

Previous TBI OSU-TBI-IDat Baseline 2

(RA)No history or single mTBI

multiple mild or greater

Psychiatric Illness

at RF Intake No psychological/ psychiatric diagnosis

Medicated, treated, and/or hospitalized for psychological/ psychiatric diagnosis


BEAM/MyBrain Risk Assessment:

Post-Injury Variables Related to Primary Aims


Frequency


measure



Substance Abuse

PROMIS Alcohol -Negative Consequences

Over-Ride Monthly T < 59 T > 60

PROMIS Severity of Substance Abuse


DyscontrolPROMIS Self-efficacy for Managing Emotions 8a

Over-Ride Monthly T > 60 T < 59

SleepPROMIS Sleep-Related Impairment 8a


Cognitive Impairment

PROMIS Cognitive Function 8a


Level of Disability MPAI Total Score Over-Ride Monthly

30-44 >45

Social/Family Isolation

PROMIS Ability to Participate in Social Roles and Activities 8a


TOTAL RISK RATING (16-32 is the possible range) Green YellowRed


MyBrain© Risk Assessment: Post-Injury

Variables Related to Secondary Aims


Frequency


measure



Pain PROMIS Pain Intensity 1a Over-Ride Monthly T < 59 T > 60

Opioid UsePROMIS Prescription Pain Medication Misuse 7a


Anger BAAQ Over-Ride Monthly 0-8 ≥9

Mood

PHQ-4: Items 1+2 Over-Ride Monthly < 2 (score 1)≥2 admin GAD-

7

PHQ-4: Items 3+4 Over-Ride Monthly < 2 (score 1)≥2 admin PHQ-

9

PHQ-9 Over-Ride Monthly 0-4 5-27

GAD-7 Over-Ride Monthly 0-4 ≥5


Intensity of RF Based on Level of Risk

Level of

Risk

Definition Intensity of Follow-up

High

(28-32)

Significant intensity or number of

biopsychosocial risk factors that

could lead to deterioration or

failure to recover, and are not

stable

RF: Minimum of weekly (in-person/telephonic)

with participant/family

Weekly RF Program Manager update

RF Program Manager determines if case

consultation with Neuropsychology or

Physician is indicated and/or case conference

required sooner

15-minute Case Conference every 2 weeks

Medium

(21-27)

Some biopsychosocial risk

factors that could lead to

deterioration or failure to recover,

but stable

RF: Minimum of weekly (in-person/telephonic)

with subject/family

Bi-Weekly RF Program Manager update

RF Program Manager determines if case

consultation with Neuropsychology or

Physician is indicated and/or case conference

required sooner

10-minute Case Conference every 4 weeks

Low

(16-20)

Few to no biopsychosocial risk

factors and evidence of good

recovery/stability of adjustment

RF: Minimum of bi-weekly (in-

person/telephonic) with subject/family

10-Minute Case Conference every 4 weeks


MyBRAIN© Self-Management Apps

Domains Type of Intervention If HIGH risk… If LOW risk…

Pain Relaxation Play their favorite music;

"Clear Picture" activity;

"New Me" activity

Relaxation Music

"New Me" activity

Free relaxation apps

Opioid Use Alterntives to urges HALT,

Clear Picture

Mindfulness for

Anxiety/Stress

Skills System skills

Anger Positive expressions of

energy or charge

Mindfulness for Anger Skills System skills

Mood Improving mood Mindfulness for

Depression

HALT


Substance

Abuse

Distractions;

Alternatives to giving

into thoughts or urges

HALT,

Clear Picture

Mindfulness for

Anxiety/Stress

HALT


Dyscontrol Awareness of

emotions/feelings

Clear Picture

HALT

Mindfulness Relaxation



Preliminary Findingsfrom BEAM & myBrain


Case 1: Sometimes it is easierto tell an avatar!

• 36 year old married male working as a carpenter

• Motorcycle crash with TBI and bilateral temporal and orbital fractures 1 month before entering RF

• Pre-injury history of opioid misuse and depression

• In Resource Facilitation intake, denied depression twice

• On BEAM-MyBrain PHQ-9, endorsed “Thoughts that you would be better off dead, or hurting yourself.”

• Triggered Resource Facilitation response and got patient into treatment


Case 2: Getting worse

• 30 year old man with 16 years of education working as a server

• Preinjury history of DUI and felony theft

• Fell our of a second story window and may have been using ETOH and Xanax at party beforehand

• Initial risk stratification was low risk

• Risk Stratification changed to medium (yellow) that resulted in more intense RF follow-up, case conferences and directed to PCP


Case 3: Question stability?

• 59 year old divorced man with

four years in combat zone, history

of domestic battery and ETOH

abuse with TBI two months ago

with left anterior, medial and

frontal lobe contusions and history

of chronic back pain and has not

worked since 2012

• Mild memory and moderate

impairment of executive functions

• Initially found to be a medium risk

• Started using Sleep-relaxation

training application in MyBrain

Now


Patients Experienced Subtle Improvements in Sleep

19

18

19

17

20

22

20

16

14

12

0

5

10

15

20

25

2 3 4 5 6 7 8 9 10 11

Ave

rage

Sle

ep

Sco

re

Follow-up Interval

Self- Reported Sleep Disturbance among TBI Patients (N=15)


Potential Relationship between Patient Pain and Mental Depression

0

1

2

3

4

5

6

0

1

2

3

4

5

6

0 2 4 6 8 10 12

Ave

rage

PH

Q-9

Sco

re

Ave

rage

PR

OM

IS P

AIN

Sco

re

Follow-up Inteval

Self-Reported Pain and Depression among TBI Patients Receiving Resource Facilitation (N=15)

PAIN PHQ-9


Summary and Conclusions

• BEAM/MyBrain is potentially a very useful tool for

surveillance and clinical management of chronic TBI

• Need to continue to develop Resource Facilitation

intervention to promote utilization of BEAM-MyBrain

• Much need for future research

• Need more data on utilization of Self-Management

Applications


Collaborators

Cori Conners, MA

Research Assistant


Jess Fann, MD

Neuropsychiatry

University of Washington

Jeremy Funk, MS

Epidemiologist


Flora Hammond, MD

Chair Physical Medicine and

Rehabilitation, Indiana University

School of Medicine

Claire Lyons, MA

Research Assistant


Devan Parrott, PhD

Director, RTOC


Laura Trexler, OTR, CBIS

ACL Grant Manager



This presentation and the research

were supported by grants from:

1) Trexler, L (PI), Hammond, F (Co-I), Corrigan, J (Co-I), Davè, S (Co-I). Reducing

opioid misuse and overdose in people with traumatic brain injury. Funded by the

Center for Disease Control and Prevention and the Indiana State Department of

Health. 2018-19.

2) Trexler, LE (PI), Hammond, F (Co-I), Ibarra, S (Co-I), Parrott, D (Co-I), Trexler LC

(Co-I). Improving Health Outcomes following Traumatic Brain Injury through Building

a TBI-informed System of Services and Supports and Resource Facilitation. Funded

by Administration for Community Living (ACL), U.S. Department of Health and

Human Services. 2018-21.

3) Trexler, LE (PI): Reducing recidivism and improving return to work in ex-offenders

with brain injury. Indiana Department of Corrections Traumatic Brain Injury State

Implementation Partnership Grant Program. 2014-2018. Funded by Health Resource

Services Administration.

4) Trexler, LE (PI) and Trexler LC (Co-PI): Developing and Translating a Statewide

System of Support and Collaboration into Local Support Networks Integrated

Through Resource Facilitation. 2009-2013. Funded by Health and Human Services,

Human Resources and Services Administration.


Disclosures

Funding for this presentation was made possible (in part) by the

Administration for Community Living. The views expressed in

written conference materials or publications and by speakers

and moderators do not necessarily reflect the official policies of

the Department of Health and Human Services, nor does the

mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.


References• Centers for Disease Control and Prevention. Moderate to Severe Traumatic Brain Injury is a Lifelong Condition [Fact

sheet]. Atlanta, GA: National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention.

https://www.cdc.gov/traumaticbraininjury/pdf/moderate_to_severe_tbi_lifelong-a.pdf

• Corrigan JD, Hammond, FM. Traumatic brain injury as a chronic health condition. Arch Phys Med Rehabil 2013; 94:

1199-1201.

• Heinemann AW, Sokol K, Gravin L, Bode, RK. Measuring unmet needs and services among persons with traumatic

brain injury. Arch Phys Med Rehabil 2002; 83: 2052-1059.

• Masel, BE and DeWitt DS. Traumatic brain injury: A disease process, not an event. J Neurotrauma 2010; 27: 1529-

1540.

• Hammond FM, Malec JF. Rethinking brain injury. Brain Injury Professional 2013; 10: 6-10.

• Malec JF, Moessner AM, Kragness M et al. Refining a measure of brain injury sequelae to predict post-acute

rehabilitation outcome: Rating scale analysis of the Mayo-Portland Adaptability Inventory. J Head Trauma Rehabil

2000; 15: 670-682.

• Patterson B, Devaraj S, and Hicks MS. Economic impact of resource facilitation: Workforce re-entry following

traumatic brain injury. Center for Business and Economic Research, Ball State University, 2017.

• Trexler LE, Trexler LC, Malec JF, Klyce D, Parrott D. (2010). Prospective randomized controlled trial of resource

facilitation on community participation and vocational outcome following brain injury. J Head Trauma Rehabil 2010;

25: 440-446.

• Trexler LE, Parrott, DR, Malec JF. Replication of a prospective randomized controlled trial for resource facilitation to

improve return to work after brain Injury. Arch Phys Med Rehabil 2016; 97: 204-210.

• Trexler, L.E. & Parrott, D.R (2018). Models of Brain Injury Vocational Rehabilitation: The Evidence for Resource

Facilitation from Efficacy to Effectiveness. J Vocational Rehabil 2018; 49: 195-203.


https://www.cdc.gov/traumaticbraininjury/pdf/moderate_to_severe_tbi_lifelong-a.pdf

Questions?


RHI-EAGLE HIGHLANDS INPATIENT AND

OUTPATIENT SERVICES

4141 Shore Drive


RHI-NORTHWEST BRAIN INJURY CENTER

9531 Valparaiso Court


RHI-CARMEL OUTPATIENT SERVICES

12425 Old Meridian Street, Suite B2

Carmel, IN 46032

RHI is a community collaboration between

Indiana University Health and St. Vincent Health

317-329-2000 | rhin.com

This presentation is provided by the:Indiana TBI State Partnership Program

Mentor State Funding Opportunity Grant No. 90TBSG0034-01-00


Documents

Welcome to today’s webinar for ACL Grantees!...Before we begin today’s webinar…a few housekeeping items: First, we would like to Thank you for attending! Please double check