evaluation of a community-based model of rehabilitation following traumatic brain injury

14
Evaluation of a community-based model of rehabilitation following traumatic brain injury Jennie Ponsford 1,2 , Helen Harrington 3 , John Olver 1,2,3 , and Monique Roper 2 1 Monash University, 2 Monash-Epworth Rehabilitation Research Centre, Epworth Hospital, 3 Epworth Hospital Melbourne, Australia In recent years there has been a growing trend towards community-based post-acute rehabilitation for individuals with traumatic brain injury (TBI), as opposed to the traditional centre-based model, based on the premise that these individuals will learn more effectively in settings where they usually have to perform. In the present study, outcomes at two years post-injury in 77 individuals with TBI, treated within the community were compared on measures of activities of daily living (ADL), vocational status, and emotional adjustment with those of 77 TBI patients individually matched for gender, age, education, occupation, post-traumatic amnesia (PTA) duration, Glasgow Coma Scale (GCS) score and time in inpatient rehabilitation, who had attended the hospital for outpatient therapy. There were no significant differences between groups in terms of employment outcomes or independence in personal or domestic ADL. However those treated in the community were less likely to be independent in shopping and financial management and reported more changes in communication and social behaviour. Due to constraints of time and resources, these patients had received fewer one-on-one therapy sessions and thus treatment costs were somewhat lower. Attendant care costs were also lower in the community treatment group. Strengths and weaknesses of community-based post-acute rehabilitation are discussed. Correspondence should be sent to Professor Jennie Ponsford, Department of Psychology, Epworth Rehabilitation Centre, Epworth Hospital, 89 Bridge Road, Richmond, Victoria, 3121, Australia. Fax: 61 3 94268742. Email: [email protected] This research was funded by grants from the Transport Accident Commission of Victoria and the William Buckland Foundation. NEUROPSYCHOLOGICAL REHABILITATION 2006, 16 (3), 315–328 # 2006 Psychology Press Ltd http://www.psypress.com/neurorehab DOI:10.1080/09602010500176534

Upload: monique

Post on 13-Apr-2017

214 views

Category:

Documents


2 download

TRANSCRIPT

Page 1: Evaluation of a community-based model of rehabilitation following traumatic brain injury

Evaluation of a community-based model of

rehabilitation following traumatic brain injury

Jennie Ponsford1,2, Helen Harrington3, John Olver1,2,3,and Monique Roper2

1Monash University, 2Monash-Epworth Rehabilitation Research Centre,

Epworth Hospital, 3Epworth Hospital Melbourne, Australia

In recent years there has been a growing trend towards community-basedpost-acute rehabilitation for individuals with traumatic brain injury (TBI), asopposed to the traditional centre-based model, based on the premise thatthese individuals will learn more effectively in settings where they usuallyhave to perform. In the present study, outcomes at two years post-injury in77 individuals with TBI, treated within the community were compared onmeasures of activities of daily living (ADL), vocational status, and emotionaladjustment with those of 77 TBI patients individually matched for gender,age, education, occupation, post-traumatic amnesia (PTA) duration, GlasgowComa Scale (GCS) score and time in inpatient rehabilitation, who had attendedthe hospital for outpatient therapy. There were no significant differencesbetween groups in terms of employment outcomes or independence in personalor domestic ADL. However those treated in the community were less likely tobe independent in shopping and financial management and reported morechanges in communication and social behaviour. Due to constraints oftime and resources, these patients had received fewer one-on-one therapysessions and thus treatment costs were somewhat lower. Attendant care costswere also lower in the community treatment group. Strengths and weaknessesof community-based post-acute rehabilitation are discussed.

Correspondence should be sent to Professor Jennie Ponsford, Department of Psychology,

Epworth Rehabilitation Centre, Epworth Hospital, 89 Bridge Road, Richmond, Victoria,

3121, Australia. Fax: 61 3 94268742. Email: [email protected]

This research was funded by grants from the Transport Accident Commission of Victoria and

the William Buckland Foundation.

NEUROPSYCHOLOGICAL REHABILITATION

2006, 16 (3), 315–328

# 2006 Psychology Press Ltd

http://www.psypress.com/neurorehab DOI:10.1080/09602010500176534

Page 2: Evaluation of a community-based model of rehabilitation following traumatic brain injury

INTRODUCTION

Traumatic brain injury (TBI) is a leading cause of disability in young people.It causes a range of physical, cognitive and behavioural impairments, whichinterfere significantly with the ability to live independently, study, work, formand maintain personal and social relationships, and pursue leisure interests(Dikmen, Machamer, & Temkin, 1993; Olver, Ponsford, & Curran, 1996).It also creates a heavy burden for caregivers and results in significant costto society.

Over the past two decades a number of specialised services have beendeveloped in an attempt to meet the needs of those with TBI, including oneat Epworth Rehabilitation Centre in Melbourne, Australia. Since 1982 thiscentre has treated patients with TBI sustained in motor vehicle or work-related accidents with funding from the Victorian no-fault accident compen-sation system, administered by the Transport Accident Commission andWorkcover Authorities. The programme aims to attain an optimal level ofcommunity reintegration in terms of living situation, and vocational, socialand recreational pursuits. Patients with TBI are admitted from acute hospitals,having inpatient rehabilitation for an average of 40 days. Prior to 1998 thoseliving locally then received outpatient rehabilitation at the hospital, attendingthe centre 3–5 days per week for 3–5 hours of physical, occupational andspeech therapy, neuropsychology and social work sessions and some groupactivities with occasional visits to home, work, shopping in the local area,and domestic activities such as cooking, usually performed in the kitchenat the rehabilitation centre.

Findings from a study of 191 TBI patients treated in this programme andfollowed up at 2 and 5 years post-injury (Olver et al., 1996), showed that morethan 90% were independent in mobility and personal and domestic activitiesof daily living (ADL). However, 60–70% reported continuing problems withconcentration, memory, executive function and behavioural regulation. Athird continued to require support in more complex activities in the homeand community, such as shopping, financial management, home maintenanceand leisure activities. More than 50% were unemployed and reported increa-sing social isolation as well as a failure to form lasting relationships, despitehaving received intensive rehabilitation.

It has become apparent that TBI individuals often have difficulty in gene-ralising what they learn in the rehabilitation centre into the community(Ponsford, Sloan, & Snow, 1995). In recent years there has been a growingtrend towards community-based post-acute rehabilitation for individualswith TBI, based on the premise that they will learn more effectively insettings where they usually have to perform. There have, however, been rela-tively few studies evaluating the impact and cost-effectiveness of community-based post-acute rehabilitative interventions. One study, by Bowen, Tennant,

316 PONSFORD ET AL.

Page 3: Evaluation of a community-based model of rehabilitation following traumatic brain injury

Neumann, and Chamberlain (1999), found no significant impact of com-munity-based intervention by a team comprising a clinical psychologist,occupational therapist and family support nurse commencing either earlypost-admission, or later following hospital discharge, relative to that ofexisting services only. Another study conducted by Powell, Heslin, andGreenwood (2002), involving a much more severely disabled group,showed that community-based therapy achieved significant gains in indepen-dence in ADL and subjective well-being, but no gains in employment orsocial interaction, when compared with provision of information aboutservices only.

In an attempt to enhance the effectiveness of its programmes, Epworth’scentre-based outpatient head injury service was replaced with a com-munity-based team of therapists in 1998. The aim was to assess andconduct therapy within the home, workplace or relevant community settings,with more active involvement of the injured individual, relatives and others inthe goal-setting and therapy processes. During the assessment process, onemember of the treating team interviews the injured person and a close-other, using a Role Checklist (Oakley, Kielhofner, Barris, & Reichler,1986) to evaluate what roles are important to the individual, how theseroles were performed prior to injury, and how they are performed now.Goals are established on the basis of this analysis, via discussion with theinjured person and family, who are thereby actively involved in the goal-setting and rehabilitation process. Assessment focuses on identifying theperson’s strengths and weaknesses and the impairments and disabilitieswhich need to be overcome to attain these goals. Therapeutic interventionstake many different forms, but are based within the relevant situation andcarried out by the most relevant team member. Generally there is interven-tion from several disciplines, and referral is also made to local services.Because of the amount of planning and travel time required, the intensityof treatment is much lower, however, with most patients being seen by agiven therapist once a week or less. The therapist might conduct a two-hour session in the home and supervise interventions carried out byattendant care workers employed to support their independence and/orfamily members, who are much more actively involved in their rehabilita-tion. Although an attempt has been made to conduct physical therapy inthe community, a significant number of patients do attend regularphysiotherapy sessions at the rehabilitation centre, due to the need for useof equipment.

This study aimed to evaluate whether this community-based model ofintervention increased participation in life roles, and achieved better out-comes in terms of return to these roles at two years post-injury, and toassess its cost-effectiveness relative to the previous centre-based outpatienttherapy intervention model. Levels of independence in ADL, employment

COMMUNITY-BASED REHABILITATION 317

Page 4: Evaluation of a community-based model of rehabilitation following traumatic brain injury

status and emotional adjustment of this group, measured at two years post-injury, were compared with those of a group of TBI patients who had receivedcentre-based outpatient rehabilitation services. It was hypothesised that TBIpatients treated by the community team would: make more significantgains in terms of independence in ADL and pursuit of leisure activities;have improved vocational outcomes; have less need for support fromothers; report fewer cognitive, behavioural and communication changes;and show lower levels of anxiety and depression as measured at two yearspost-injury than those treated in the hospital-based outpatient treatmentmodel, once injury severity, age and duration of inpatient treatment werecontrolled for. It was also hypothesised that costs for community-basedtherapy would be lower than for centre-based therapy.

METHOD

Participants

The experimental group comprised patients with moderate to severe TBIwho agreed to participate in the project and were treated within the com-munity-based therapy (CT) programme run by Epworth RehabilitationCentre. As the centre-based outpatient service has now been replaced bythe CT programme, the control group was recruited retrospectively fromthose TBI patients already treated in the original centre-based outpatienttherapy (OP) programme, who had also attended the follow-up clinic attwo years post-injury. The OP comparison group was matched one-on-onewith patients in the CT group on the basis of gender, age, years of education,premorbid employment, marital status, injury severity in terms of duration ofpost-traumatic amnesia (PTA) and Glasgow Coma Scale (GCS) score, andtime spent in the inpatient programme.

Measures

The following measures were obtained at two years post-injury:

Structured Outcome Questionnaire (Ponsford et al., 1999). Independencein personal (feeding, dressing, grooming), light domestic (meal preparation,washing up, dusting), heavy domestic (heavy cleaning, making beds,laundry, gardening), and community activities of daily living (shopping andfinancial management) was rated on a six-point scale as follows: 1 ¼ totaldependence; 2 ¼ dependence (minimal participation); 3 ¼ dependence(active participation); 4 ¼ minimal assistance only; 5 ¼ supervision only;6 ¼ independence with or without aids. Scores in the first three domainswere added to give a total score for that domain. Those studying or employed

318 PONSFORD ET AL.

Page 5: Evaluation of a community-based model of rehabilitation following traumatic brain injury

in the open workforce full- or part-time were scored 1 and those unemployedor not in the labour force scored 0. Mobility was rated on an eight-point scalefrom 1 ¼ confined to bed to 8 ¼ previous level. Independence in use of trans-port was documented on a five-point scale from 1 ¼ fully dependent to5 ¼ able to drive. Patients were asked to comment on changes in theirability to engage in previous or alternative leisure activities, rated on a four-point scale ranging from 1 ¼ return to no previous leisure activities to4 ¼ return to all previous leisure activities, support from close others relativeto pre-injury, rated on a three-point scale (more support, same support, or lesssupport), and changes in communication (making speech understood, follow-ing conversation, thinking of words), cognitive functions (forgetfulness,slower thinking, difficulty concentrating and planning, mental fatigue), beha-viour (irritability, impulsivity, social behaviour and self-centredness), andemotional state (anxiety and depression) using a three-point scale(0 ¼ change that interferes with daily activities, 1 ¼ change that does notinterfere with daily activities, 2 ¼ no change).

Handicap levels: Craig Handicap Assessment and Reporting Technique(CHART; Whiteneck et al., 1992). This was used as a multi-dimensionalobjective measure of handicap. Using a questionnaire format, it was com-pleted by the injured person, in consultation with a close other. The followingscales were used: Physical Independence, Mobility, Occupation, and SocialIntegration. The raw score from each subscale is converted to a scaledscore, ranging from 0 to 100, with 0 representing maximum handicap and100 representing the “normal” range.

Costs and number of therapy sessions. With participants’ permission,these were obtained from the databases of the insurer, either the TransportAccident Commission or the Victorian Workcover Authority.

Procedures

Consecutive admissions to the CT programme over a two-year period wereapproached on admission to consent to participate in the project. Demo-graphic and injury-related information was gathered at this time. Theywere assessed by a research psychologist who was independent of the treatingteam, at three-monthly intervals as they progressed through the programme,at discharge, and at one and two years post-injury. This study focuses onstatus at two years post-injury. OP control group participants were recruitedretrospectively from those who had attended the centre-based programme andattended a follow-up clinic two years post-injury. They had given permissionfor use of the data for research evaluating the programme. They were matchedindividually with CT participants on the basis of age, gender, education,

COMMUNITY-BASED REHABILITATION 319

Page 6: Evaluation of a community-based model of rehabilitation following traumatic brain injury

pre-morbid employment, marital status, PTA duration, GCS score and timespent in the inpatient programme. Only CT participants for whom closematches were available were included in this study.

Statistical analysis

The data were checked for homogeneity of variance and normality ofdistribution, and one outlier removed in the costing data. Independentsamples t-tests were used to compare group demographic and injury detailsand scores on the rating scales for ADL, mobility and use of transport,leisure activities, CHART subscales, changes in communication, cognition,behaviour and emotional state, number of half-hour sessions billed bytherapists, and dollar costs of travel and attendant care. A repeated measuresANOVA was used to examine the relative impact of each treatment on ADLrating scores. Chi-square was used to compare the percentage from eachgroup who were employed or studying at two years. Alpha was set at .05but actual p values have been reported.

RESULTS

Participants

Seventy-seven participants with moderate to severe TBI from the CT pro-gramme were matched with 77 OP controls. Both groups comprised 73%males. Those in the CT group had a mean age of 35.43 years (SD ¼ 16.65)and a mean of 11.56 years of education (SD ¼ 2.42). Sixty-three percentwere single. They had an average PTA duration of 28.28 days(SD ¼ 25.50) and a mean initial GCS score of 8.22 (SD ¼ 4.37). Sixty-sixpercent were employed prior to injury, 12% were students, 16% were notin the labour force and 6% were unemployed. The mean age of those in theOP control group was 33.78 years (SD ¼ 15.41) and mean years of educationwas 11.15 years (SD ¼ 2.54). Sixty-one percent of OP controls were single.They had a mean PTA duration of 26.07 days (SD ¼ 26.27) and a mean GCSscore of 7.76 (SD ¼ 4.13). Seventy percent of this group were employed priorto injury, 9% were students, 12% were not in the labour force and 9% wereunemployed. There were no statistically significant differences betweengroups on any of these variables. Group comparisons of independence inADL at commencement of CT/OP therapy are set out in Table 1. Therewere no significant differences in ADL independence prior to CT/OPtherapy. Patients were seen, on average, within 34 days of two years post-injury (SD ¼ 38.42, range ¼ 1–180 days).

320 PONSFORD ET AL.

Page 7: Evaluation of a community-based model of rehabilitation following traumatic brain injury

Return to employment/study

Of the entire CT treatment group, 38% were employed two years post-injury,8% were studying and 54%were unemployed. Of the entire OP control group,40% were employed at two years, 4% were studying and 56% wereunemployed. These differences were not significant, x2(1) ¼ .976,p ¼ .323. Considering those studying or employed prior to injury only,49% from the CT group were employed at two years post-injury and 4%were studying, whereas 52% from the OP control group were employed attwo years and none were studying.

Independence in activities of daily living

Results obtained in relation to independence in ADL at two years post-injury are set out in Table 2. A repeated measures ANOVA indicatedthat both groups were showing higher levels of independence in personal,F(1, 73) ¼ 20.12, p ¼ .00, and light domestic ADL at two years,

TABLE 1ADL status on commencement of OP or CT treatment

CT Mean

score

OP Control

Mean score t p

Personal ADL 5.4 5.6 20.899 .370

Light domestic 4.9 5.0 20.658 .512

Heavy domestic 4.3 4.8 21.88 .080

Shopping 4.3 4.5 0.133 .340

Financial management 4.7 4.5 0.622 .597

1 ¼ total dependence, 2 ¼ dependence (minimal participation), 3 ¼

dependence (active participation), 4 ¼ minimal assistance, 5 ¼ supervision,

6 ¼ independence

TABLE 2ADL status of CT and OP control groups at two years post-injury

CT Mean

score

OP Control

Mean score

Personal ADL 5.8 5.7

Light domestic 5.4 5.6

Heavy domestic 4.7 4.8

Shopping 4.7 5.2

Financial management 4.8 5.2

1 ¼ total dependence, 2 ¼ dependence (minimal participation), 3 ¼

dependence (active participation), 4 ¼ minimal assistance, 5 ¼

supervision, 6 ¼ independence

COMMUNITY-BASED REHABILITATION 321

Page 8: Evaluation of a community-based model of rehabilitation following traumatic brain injury

F(1, 73) ¼ 7.29, p ¼ .01, but there was no significant group by treatmentinteraction for either variable. Levels of independence in both groups weresomewhat lower for heavy domestic activities, and there was no significantgroup difference over time and no significant group by treatment interactionfor this variable. On the other hand, there was a significant group by treatmentinteraction for the financial management variable, indicating that, relative tothe OP control group, the CT group was significantly more likely to report theneed for ongoing supervision and/or assistance in financial management attwo years post-injury, F(1, 65) ¼ 8.36, p ¼ .05. In the case of shopping,the trend in this direction did not reach significance, with both groupsmaking gains, F(1, 68) ¼ 11.83, p ¼ .00.

Mobility, use of transport, leisure activities, support from closeothers and social isolation

Differences in scores on the Mobility scale were not statistically significant(Table 3), with more than half of both groups being able to run or jump orback to their pre-morbid level of mobility. From Table 3 it is also evidentthat there were no statistically significant differences in terms of indepen-dence in use of transport, although only 56% of those in the CT had returnedto driving, as opposed to 63% of the OP control group. Over 90% of bothgroups had returned to at least a few previous leisure interests and therewere no statistically significant group differences on this variable. Those inthe CT group were significantly more likely to say they required moresupport from close others relative to pre-injury than those in the OP controlgroup (40% vs 19%) (see Table 3). Reporting of social isolation was fairlysimilar, with 47% of those in the CT group reporting that they had lostfriends or become more socially isolated versus 41% of OP controls.

Handicap levels on the CHART

Results obtained by the two groups on the four CHART subscales are shownin Table 4. Those in the CT group showed a significantly higher level of

TABLE 3Independence in mobility, use of transport, return to previous leisure

activities and support from close others relative to pre-injury

CT Mean

score

OP Control

Mean score t p

Mobility 5.7 6.1 21.42 .161

Use of transport 4.0 4.3 20.388 .701

Leisure 3.2 3.6 1.877 .085

Support from close others 1.6 2.0 22.49 .008�

�p , .01

322 PONSFORD ET AL.

Page 9: Evaluation of a community-based model of rehabilitation following traumatic brain injury

Physical Independence than OP controls. However those in the OP controlgroup had significantly higher scores on Mobility. There were no differenceson the other scales.

Self-reported changes in communication, cognitionand behaviour

There were significant differences in reported communication difficulties,with the CT group being more likely to report ongoing difficulties(Table 5). Fifty-four percent of those in the CT group reported difficultymaking their speech understood by others versus 26% of controls. Fortypercent reported difficulty following conversation, versus just 10% of thosein the control group. The differences were statistically significant. On theother hand, a high proportion of both groups reported word-findingdifficulties.

As can be seen from Table 6, there were no statistically significant differ-ences in reporting of other cognitive difficulties. In the domain of behaviouralchanges, CT participants were significantly more likely to report the presenceof inappropriate social behaviour, 33% of those in the CT group reportingsuch behavioural changes, versus 14% of controls. Forty percent of CT par-ticipants reported greater impulsiveness, versus 26% of controls, although

TABLE 4CHART subscale scores

CT Mean

score

OP Control

Mean score t p

Social integration 79.7 81.0 20.308 .759

Occupational 70.5 68.3 0.388 .699

Mobility 85.6 93.6 22.8 .005�

Physical independence 99.0 92.9 2.9 .004�

�p , .01

TABLE 5Changes in communication

CT Mean

score

OP Control

Mean score t ps

Motor speech problems 1.48 1.78 22.87 .005�

Following conversation 1.60 1.90 23.58 .001�

Word finding 1.48 1.46 0.906 .906

1 ¼ yes, 2 ¼ no; �p , .01

COMMUNITY-BASED REHABILITATION 323

Page 10: Evaluation of a community-based model of rehabilitation following traumatic brain injury

this difference did not reach significance. There were no significant differ-ences in reporting of other behavioural changes (Table 6).

Emotional adjustment

There were no significant differences in reporting of anxiety and depressionrelative to pre-injury. Fifty four percent of the CT group reported feelingmore anxious than prior to injury versus 55% of controls. Seventy-onepercent reported being more depressed as opposed to 62% the OP controlgroup. None of the differences was statistically significant.

Therapy received

The median number of individual half-hour therapy sessions billed by therapytype are shown in Figure 1, excluding psychology, because the psychologysessions charged included travel time, whereas this was not the case forother therapies. There was little difference in the number of physiotherapysessions, which remained high, because this treatment was still beingcarried out at the rehabilitation centre. Those in the CT group receivedfewer sessions of occupational therapy, speech therapy and social workalthough none of these differences reached statistical significance. The ses-sions billed included planning time and time spent on the telephone, whichwas considerably higher for the CT treatment. In most cases the patientshad less than half the direct contact time with these therapists than thecontrol group.

TABLE 6Changes in cognition and behaviour

CT Mean

score

OP Control

Mean score t p

Planning difficulties 1.70 1.44 1.76 .181

Concentration 1.85 1.59 0.432 .713

Forgetfulness 2.13 1.87 0.381 .648

Slower thinking 2.00 1.84 0.743 .421

Fatigue 1.93 1.49 1.8 .138

Irritability 1.85 1.67 1.02 .249

Impulsiveness 1.65 1.28 1.74 .092

Inappropriate social behaviour 1.70 1.18 2.24 .009�

Needs prompting 1.84 1.61 0.582 .614

Self centredness 1.45 1.34 0.747 .783

Social isolation 1.78 1.54 0.981 .384

1 ¼ no, 2 ¼ yes, but does not interfere with daily activities, 3 ¼ yes, and interferes with daily

activities; �p , .01

324 PONSFORD ET AL.

Page 11: Evaluation of a community-based model of rehabilitation following traumatic brain injury

Median costs of travel and attendant care in total dollars are set out inFigure 2. For the OP control group they represent the cost of taxi transportto the hospital for therapy and therapist travel time into the community(except for psychology). These costs were somewhat higher for the OPcontrol group, although again the differences did not reach statisticalsignificance.

DISCUSSION

The results of this study evaluating the impact of community-based treatmentwere not consistent with our hypotheses. In many domains, there were nosignificant differences between the two groups in terms of: employment

92

3730

6

47 47

13

90

0102030405060708090

100

Physio OT

Speec

h

Social

Wor

k

Num

ber

Community

Control

Figure 1. Median number of therapy sessions for physiotherapy, occupational therapy, speech

therapy, and social work.

573.00

3948.00

1420.00

6177.00

2429.00

734.00

0.00

1000.00

2000.00

3000.00

4000.00

5000.00

6000.00

7000.00

Travel

Att Care

Total

Cos

t $

Community

Control

Total includes costs for gym, childcare etc

Figure 2. Median costs for travel and attendant care by treatment group.

COMMUNITY-BASED REHABILITATION 325

Page 12: Evaluation of a community-based model of rehabilitation following traumatic brain injury

outcomes; independence in personal and domestic ADL; mobility; return toleisure activities; occupation and social integration as measured on theCHART; self-reported cognitive changes; social isolation; and emotionaladjustment. However, those TBI patients treated in the CT model of carewere less likely than those in the OP group to report being independent infinancial management, obtained significantly lower scores on the Mobilitysubscale of the CHART, and were more likely to report that they requiredmore support from close others relative to pre-injury. They were alsomore likely to report the presence of problems with communication andinappropriate social behaviour. Arguably, those in the CT group had ahigher level of awareness of their limitations and need for support. Thosein the CT did show higher levels of physical independence than the OPcontrol group, supporting the benefit of the amount of physiotherapy theyhad received relative to other therapies. However, it had been hoped thatthey would be functioning at a more independent level in more complexcommunity-based activities.

Although there were no statistically significant differences in costs of thetwo models of therapy, the costs of centre-based treatment were somewhathigher overall, in terms of treatment sessions, travel costs and costs of atten-dant care. The potential savings in implementing the community-basedtreatment need to be weighed against the relative benefit of each form of inter-vention. Those treated in the CT had somewhat less face-to-face contact withoccupational therapists, speech therapists and social workers. This may havehad a negative impact on their outcomes in terms of independence in financialmanagement, use of transport and in terms of their communication. Thenumber of patients being treated by the community team grew exponentiallyover the period of the study. Patients had to be serviced by a team comprisinga part-time co-ordinator, two occupational therapists, 1.5 speech pathologists,1.5 psychologists, a 0.5 social worker and a part-time vocational therapist.Much time was spent in travelling and co-ordination of the programmes.The patients were receiving, on average, only about an hour per week ofany form of therapy, including physiotherapy. Excluding physiotherapy,they received an average of an hour per fortnight. This frequency ofcontact with skilled therapists may not have been sufficient to achieveoptimal gains in some functional activities. We remain committed to themodel of goal-setting according to the injured person’s roles, active involve-ment of the injured person and family at all stages of the rehabilitationprocess, and the importance of training in the setting in which tasks are nor-mally performed. However, it seems that such training, at least for certainactivities, may need to be more intensive than it was for these patients andit should be carried out by skilled therapists. On the other hand, the potentialcost savings of the community-based model may mean that this model of careis preferable from the funding agency’s perspective and, given that the

326 PONSFORD ET AL.

Page 13: Evaluation of a community-based model of rehabilitation following traumatic brain injury

differences in outcomes were evident in only a few areas, could arguably bemore cost-effective.

A limitation of this study is the fact that the OP control group was recruitedretrospectively. They were treated between 1989 and 1998, whereas those inthe CT group were treated between 1998 and 2001. It is possible that otherfactors influenced outcomes in these groups. The model of inpatient carehas remained relatively stable over the past 10 years, with the same doctorsco-ordinating treatment and running the follow-up clinic. Nevertheless,subtle factors may have influenced the quality of treatment. Other socialfactors may have influenced return to work rates or emotional adjustment.The demographics of the patient group did change somewhat, such that notall of those in the CT group could be matched with a patient from the OPcontrol group. It is also possible that the group attending the follow-upclinic may have represented a somewhat self-selected sample. On the otherhand, those experiencing problems would be more likely to attend thefollow-up clinic, which would mitigate against the findings of the presentstudy. Unfortunately, the only way of quantifying the amount of therapyreceived by the two groups was from billing data. This precluded a detailedanalysis of the precise nature and duration of actual face-to-face contactwith therapists. Future studies would benefit from the inclusion of this infor-mation, in order to clarify which aspects of intervention are most effective.

In the meantime, the community team has been reviewing its practices inresponse to these findings and is implementing a number of changes, with theaim of increasing the amount of time spent in direct client contact. It is limit-ing the distance travelled to see clients, and clients are being seen more oftenat the centre. An attempt is being made to increase the frequency of therapistcontact focusing on ADL, with a plan to use allied health professionalsworking under the supervision of occupational therapists to implement this.It would appear that patients benefit from the support of contact with otherhead-injured patients. In response to this finding, a transitional programmewill be introduced to support clients as they move into the communityfrom inpatient care. Patients will be invited to attend centre-based groupsfocusing on use of memory strategies, conversational skills, coping skillsand study skills, on days when they attend physiotherapy. A more aggressiveapproach will be taken with regard to return to work. The impact of thesechanges to the model of care will be evaluated in an ongoing fashion.

REFERENCES

Bowen, A., Tennant, A., Neumann, V., & Chamberlain, M. A. (1999). Evaluation of a

community-based neuropsychological rehabilitation service for people with traumatic

brain injury. NeuroRehabilitation, 13(9), 147–155.

COMMUNITY-BASED REHABILITATION 327

Page 14: Evaluation of a community-based model of rehabilitation following traumatic brain injury

Dikmen, S., Machamer, J., & Temkin, N. (1993). Psychosocial outcome in patients with

moderate to severe head injury: 2-year follow-up. Brain Injury, 7, 113–124.

Oakley, F., Kielhofner, G., Barris, R., & Reichler, R. K. (1986). The Role Checklist:

Development and empirical assessment of reliability. Occupational Therapy Journal of

Research, 6, 157–170.

Olver, J. H., Ponsford, J. L., & Curran, C. A. (1996). Outcome following traumatic brain injury:

A comparison between 2 and 5 years after injury. Brain Injury, 10(11), 841–848.

Ponsford, J., Olver, J., Nelms, R., Curran, C., & Ponsford, M. (1999). Outcome measurement in

an inpatient and outpatient traumatic brain injury rehabilitation programme. Neuropsycho-

logical Rehabilitation, 9, 517–535.

Ponsford, J., Sloan, S., & Snow, P. (1995). Traumatic brain injury: Rehabilitation for everyday

adaptive living. Hove, UK: Psychology Press.

Powell, J., Haslin, J., & Greenwood, R. (2002). Community-based rehabilitation after severe

traumatic brain injury: A randomized controlled trial. Journal of Neurology, Neurosurgery

and Psychiatry, 72, 193–202.

Whiteneck, G. C., Charlifue, S. W., Gerhart, K. A., Overholser, D., & Richardson, G. N. (1992).

Quantifying handicap: A new measure of long-term rehabilitation outcomes. Archives of

Physical Medicine and Rehabilitation, 73, 519–526.

Manuscript received April 2004

Revised manuscript received October 2004

328 PONSFORD ET AL.