Special Report: Focus on TBI Programs

Program ventures into less-traveled territory

Group members support each other

A Lima, OH, day rehab program serving patients who have sustained traumatic brain injuries (TBI) provides extensive training in activities of daily living (ADL), job skills, and maintaining independence.

Relying on a multidisciplinary team working with a small group of TBI patients, the program has successfully launched patients into desired community roles and ADL tasks.

"The program allows for individuals within the group to be each other’s support, so it doesn’t always come from the therapist," says Kelley Recker, MS, CCC-SLP, administrative director for physical medicine and rehabilitation at St. Rita’s Medical Center in Lima, OH. The hospital has 20 inpatient rehab beds.

Called the Ventures Program, it operates on a day rehab format with sessions lasting six hours per day, three days a week and involving speech therapy, occupational therapy, physical therapy, recreational therapy, neuropsychology, and a vocational specialist on a consulting basis.

Housed in the acute rehab facility, the Ventures Program has the Easy Street environment, which includes a simulated grocery store, bank, church, horticultural room, and workshop area, and a functional apartment that contains a kitchen and laundry area, says Yvette Watson, MSW, ACSW, LSW, case manager of the Ventures Program.

"A big component of our program, and this is why we’re different, is the group format," Watson explains. "Typically we don’t have more than five patients at a time in the program, because to accommodate more would be too overwhelming."

Most patients are in the program for one month to six weeks, and the same patients won’t be there each day, although the groups typically consist of two to five individuals, Watson says.

The program mostly bills payers for the separate therapy services because most don’t have a group rate for therapies, Watson says.

"In some fortunate instances, we were able to negotiate a daily rate," Watson says. "If there’s case management involved or if the payer wants to do a group rate, we can negotiate a group rate."

The patients admitted to the program typically need only minimal physical assistance in moving. The few who have been in wheelchairs have been able to transfer themselves to bathroom facilities and are independent in bowel and bladder. Their TBI diagnosis typically has resulted in cognitive limitations, and the patients must be referred by a physician. Basic neuropsychological testing is provided.

Watson measures outcomes on a quarterly basis, and the program provides follow-up with patients at six months and one year. By six months, patients typically are back at work part time or attending school, even when they might not yet be driving. Also, most patients have returned to doing their normal activities by this time, such as yard work or church involvement.

Here’s a typical weekly schedule of the Ventures Program:

  • Monday: At 10 a.m., patients have an orientation to the time and day and then are involved in a thinking skills group led by a speech pathologist.

Patients review their goals and assess their progress, looking at making further plans and organizing their assignments for that day.

Problem-solving skills highlighted

As part of the thinking and problem-solving training, patients work on their reasoning skills and learn compensatory strategies and speech pragmatics. For example, a patient may be asked to read a particular newspaper article and present that information to the group, or the therapist may give patients some hypothetical situations to consider and ask them what they would do if these happened to them. "We’ll use anything that involves problem-solving," Watson says.

At 11 a.m., there is a community lunch planning group that lasts from 30 to 45 minutes. This session is for planning the lunch outing that’s held on Wednesday. It’s followed by a 15-minute break.

From noon until 1 p.m., patients go into the dining room and learn dining or cooking skills, depending on the week.

"One week they’ll go down to the cafeteria at St. Rita’s and order through the line, and they have an hour for lunch on that day," Watson says. "On alternating weeks, they’ll have cooking groups, and on alternating Fridays they go to a grocery store and purchase items for preparing a meal."

The occupational therapist teaches the group the dining room and cooking skills, including following a recipe.

After lunch, the group learns basic home management training in safety awareness, homemaking responsibilities, and other activities of daily living.

Then at 2:30 p.m., the group has a community exercise with the physical therapist, who takes the group to the outpatient facility’s exercise room where they work with Nautilus equipment and other exercise machines.

"We also have a therapeutic pool, and they’ll occasionally go into the pool for therapy," Watson says. "Patients have to be pretty mobile to come into our program, and they’ll need additional physical therapy as well."

Patients are taught to improve their ability to move and do ADLs by engaging in home exercise programs when they are not at the rehab facility.

  • Wednesday: At 9 a.m., the group begins the home management session, learning the same safety, financial planning, and problem-solving skills that they covered on Monday.

From 10 a.m. to 11 a.m., the orientation and thinking skills group is run jointly by the neuropsychologist and the speech therapist.

The community re-entry planning group plans the Friday lunch outing at 11 a.m., spending half an hour making phone calls, reviewing maps, and covering other details.

The Wednesday lunch outing begins at 11:45 a.m. and lasts until 1:45 p.m. These outings sometime take place outside the Lima area, so two hours are allotted to give the group plenty of travel time. "We have money allotted for lunch outings, and the therapists rotate on who takes them out," Watson notes.

After lunch, from 2 p.m. to 3 p.m., the neuropsychologist leads a coping skills group in which patients are taught to adjust to their brain injury. The group essentially has a psychotherapy-style session in which patients can discuss how their families are dealing with them, as well as their thoughts and feelings about changes in their daily lives, Watson says.

  • Friday: Fridays also begin at 9 a.m. with an orientation and thinking skills group led by the neuropsychologist. At 10 a.m., the occupational therapist holds the home management group. From 11 a.m. to noon, there is recreational instruction. Patients play different board games, such as Scrabble and Life.

"We try to purchase games that will challenge them mentally, and we incorporate something a little lighter for them," Watson says. "They have to be responsible for leading the group in reading instructions or teaching the game to another participant."

From noon to 1 p.m., the group learns dining room skills with the physical therapist, either by going to the hospital’s dining room or to a restaurant that is within walking distance of the hospital.

From 1 p.m. to 3 p.m., the community re-entry group goes on an outing. The groups have visited local libraries in Lima and in neighboring towns. They’ve also visited museums and have even gone bowling when that was what the group members desired.

"We’ve had gentlemen who have worked with their hands and done woodworking, so the group will go to Lowe’s and purchase products for making something within the group, or they’ll price items for a project they’re doing at home," Watson says.

Other trips have gone to area malls, including Christmas shopping in December, and the group has taken tours at area manufacturing plants or the newspaper building.

The group has also visited a go-cart park, played video games, and played miniature golf.

  • Tuesday and Thursday: Patients who desire to return to work or school sometimes will meet with the vocational specialist on Tuesdays or Thursdays. Then the vocational specialist will meet the patient’s employer or college counselor and work out a plan for the patient’s return.

"The major tenet of the program is to have patients either in school or working to get them back into some type of normal routine when they leave the program," Watson says. "A lot of times they are not immediately ready to go back, but working with the vocational counselor makes it easier for them to return to work or school."

The vocational specialist teaches employers and school counselors about the TBI patient’s limitations and helps them decide how to make special modifications, such as providing a tutor or permitting the student to take longer in examinations.

  • Reunion: During the holiday season, the Ventures Program invites past graduates to return for a reunion with light refreshments. Staff members attend, which gives them an opportunity to find out how former patients are doing with their recovery. Attendees can bring their spouses and children. The reunion is typically held in December and is provided on a drop-in basis.

Need More Information?

  • Kelley Recker, MS, CCC-SLP, Administrative Director for Physical Medicine and Rehabilitation, St. Rita’s Medical Center, 730 West Market St., Lima, OH 45801. Telephone: (828) 645-8208.
  • Yvette Watson, MSW, ACSW, LSW, Case Manager, Ventures Program, St. Rita’s Medical Center, 730 West Market St., Lima, OH 45801. Telephone: (419) 227-3361.