Traumatic brain injury (TBI) is considered a chronic health condition, not an event (Masel & DeWitt, 2010).
Moderate to severe TBI has been shown to be both disease causative and disease accelerative (Masel, 2009). A subset of individuals with moderate to severe TBI may demonstrate decline over time in terms of physical functioning, psychosocial factors, self-care, behavioral choices, and may also develop co-morbid conditions (Corrigan & Hammond, 2013). This evidence requires a clinical approach that addresses moderate to severe TBI as a chronic health condition, much like other chronic conditions such as diabetes and cardiovascular disease. Chronic disease management models frequently employ long-term case management to: educate patients and families about the disease or chronic condition; identify risk factors and symptoms early-on to prevent onset of secondary conditions; provide evidenced-based interventions to minimize disease progression; teach appropriate self-management techniques; and provide regular, scheduled follow-up to ensure patient compliance and follow-through. While long-term (i.e., 1-2 year) scheduled telephone interventions have been used with the TBI population in previous research studies, their effects on maintenance of function, health and emotional status, community participation, and re-hospitalization have been mixed. Additionally, most studies have followed patients after release from acute (i.e., hospital-based) rehabilitation (Bell, Brockway, Hart, et al., 2011) vs. post-acute rehabilitation
Specific Aims: The aims of the current investigation include: 1) to develop objective criteria to classify patients into one of three follow up categories – supported self-management, symptom/disease management, and intensive case management; 2) to determine the impact of intensive, long-term case management on maintenance of post-acute rehabilitation outcomes; 3) to determine which group of patients benefit most from intensive, long-term case management, and 4) to determine patient/family variables that are associated with responsiveness to intensive, long-term case management.
Background and Significance: Existing evidence suggests that employing a chronic disease management model with telephone-based intervention can improve the management of conditions such as diabetes (Assal, Ekoe, Lacroix, et al., 1987; Greenfield, Kaplan, Ware, et al., 1988) and heart disease (Johnson, 2000; Mittag, China, Hoberg, et al., 2006) in the general population. These interventions have also shown promise in supporting positive lifestyle changes, such as smoking cessation (Feenstra, Hamberg-van Reenen, Hoogenveen et al., 2005), and in reducing symptoms and enhancing treatment compliance in adults with depression (Fortney, Pyne, Edlund, et al., 2007; Kaon, Rutter, Ludman et al., 2001.). Scheduled telephone interventions and telephone follow-up have been used with the stroke and TBI populations to improve compensatory strategy use for memory impairments (Bourgeois, Lenius, Turkstra, et at., 2007), and to assist with problem-solving and relieve care giver burden for family members of persons with TBI (Rivera, Elliott, Berry, et al., 2008). Scheduled telephone counseling has also been used to enhance maintenance of acute rehabilitation outcomes for persons with moderate to severe TBI. Bell and colleagues (2005) compared scheduled telephone intervention with usual follow-up in 171 adults with moderate to severe TBI over the first year post injury in a randomized controlled trial. Analyses revealed better outcomes for the scheduled telephone intervention group as compared to usual follow up on measures of function, mood, community integration, and well-being. A larger, multicenter randomized controlled trial was undertaken to replicate and extend these results; however, analyses revealed no significant differences between those receiving scheduled telephone intervention and usual follow up (Bell, Brockway, Hart et al., 2011). The purpose of the present study is to employ and test a chronic disease management model using long-term case management and follow-up on maintenance of rehabilitation outcomes after discharge from post-acute brain injury rehabilitation.
Experimental Design and Methods: All consecutive admissions to TLC for post-acute brain injury rehabilitation that meet inclusion criteria during fiscal year 2014-2015 will be eligible for participation in the study. All subjects will be consented prior to enrollment in the study. A longitudinal, case controlled design will be employed. Patients admitted to TLC-Galveston will participate in the intervention (i.e., long-term case management) condition. Patients admitted to TLC-Lubbock will participate in the control (i.e., usual follow-up) condition. Patients in the experimental and control conditions will be matched on certain demographic variables (i.e., age, gender, education, marital status, and co-morbidities) and injury characteristics (i.e., type of injury, severity of injury, length of time since injury). At admission, information will be collected on all participants (both intervention and control condition) on demographic variables and injury characteristics. Within one week of admission and discharge, all participants (both intervention and control conditions) will be administered objective measures of function (Mayo-Portland Adaptability Inventory-4), activity limitations (Disability Rating Scale), supervision level (Supervision Rating Scale), mood (Center for Epidemiologic Studies Depression Scale), and life satisfaction (Satisfaction with Life Scale). At 1, 6, and 12 months post discharge, all participants will be contacted by phone and objective measures of function, activity limitations, supervision level, mood, and life satisfaction will be re-administered. This follow-up and reassessment scheduled will serve as the usual follow-up (UFu) condition for the control group. For patients in the experimental group, a comprehensive, individualized follow-up care plan will be developed within 14 days of discharge. Case managers will provide scheduled, telephone follow-up at 2 and 4 weeks post discharge, and at 2, 3, 5, 7, 9, and 12 months post discharge. Calls will focus on implementation of the individualized care plan. Although TLC initiated follow-up calls will occur on the schedule outlined above, participants and/or families my call the facility at any time.