Alixis Van Horn, MSN APRN-C Jennifer Nardi, MSPT Dawn Gordon, MOT, OTR/L Rachael Levy, MA, CCC-SLP

Neurology Day Rehabilitation Program (NDR)

NDR: Evolution

• Model program at sister facility • Focused on neurological injuries • Secondary goal of collecting data

– Support 3rd party payment for rehab as a clustered service

NDR: Development

Needs Assessment: • Gaps in service • Population in geographic catchment • Competition

NDR: Development

• Identify stakeholders • Build a vision and values • Initiate team building

– Creating culture – Skill mix

NDR: Values

• Comprehensive – Acknowledge all domains impacted

• Cohesive – Work as a team

• Holistic – Treatment driven by the patient

• Promote Coordination of Care

NDR: Translation of Values

Comprehensive: • What are the deficits? • What are the goals? • Who else is involved? • What additional supports and resources

are needed?

• Insert photo of space

NDR: Translation of Values

Cohesive: • Strong commitment to the program and

the team • Foster constant, meaningful

communication • Systems and infrastructure supports • Accountability

NDR: Translation of Values

Holistic: • Embracing the patient as a whole person • Acknowledging concerns • Including family and loved ones • Education and support

NDR: Translation of Values

Coordination of Care: • Other HCP’s and their plan • Referrals • Communication of concerns, changes • Advocacy • Ancillary Services

Initial Goals

• 25 enrollees • Stable staff

Emerging Goals

• Ancillary services • Offshoot programs • Specialize staff • Fundraising

Ancillary Services

• Social work • Psychotherapy • Neuropsychology • Massage • Driving evaluations

Ancillary Services

WISH LIST • Music therapy • Animal therapy • Peer counseling • Vocational counseling • Spasticity clinic

Animal Therapy • Harbor Grace

Outreach

• Working with UMASS residents • Clinical rotations for students • Stroke support group • Collaboration with neurology

NDR: Screening

• Neurologic injury • Preferably under 12 months since injury • No underlying dementia • No active substance abuse • Active MH dx under care of psychiatrist • Continent or with caregiver assistance

Physical Therapy

• Land and aquatic – LiteGait – LSVT BIG – Neuromuscular electrical stimulation – AlterG Bionic Leg – Simulated environments

Occupational Therapy

• Land and aquatic • Task and environmental simulation • BTE Simulator II • Neuromuscular electrical stimulation • Cognitive interventions • Driver readiness skills

Speech Therapy

• Cognitive interventions • Memory interventions • Executive function interventions • Dysphagia therapy • LSVT LOUD • Assistive voice technologies • Simulated environments

Nurse Practioner

• Care coordination • Neurologic management

– Seizures, spasticity, depression/anxiety, PBA • Education • Support for families and patients

Additional Offerings

• Groups • Graduation • Social outings

Program Statistics

• ~150 referrals, only 5 inappropriate • About 60% enrollment rate • LOS: 4 weeks – 18 months • Rolling admissions

Barriers to Enrollment

• Transportation – Distance – Variable schedule – Frequency of

appointments – Variable onsite time

– Need for assistance – Cost – Caregiver burden – Stigma

Barriers to Enrollment

• Insurance benefits • Medicare: cap for Speech and PT $1940, cap for OT $1940.

– After cap is reached, will extend to $3700 • Only for medical necessity

– Reduced patient cost in the presence of a secondary payer

Barriers to Enrollment

• Medicaid/MassHealth – Visit limits per year or re-assessment period – Multiple insurance plans with varying

coverage – No copay

Barriers to Enrollment

• Managed Care – Accept most commercial insurance – Policy dependent

• Visit limits per year or re-assessment period • Copay on most primary plans

Who We Serve

Traumatic Brain Injury

Gabrielle Gifford

Stroke

Dick Clark

Metastatic or Primary Tumor

Senator Ted Kennedy

Movement Disorders

• Ataxia • Huntington’s • Parkinson's • Multiple Sclerosis

Spinal Cord Injury

Christopher Reeves

Others

• Anoxic brain injury • Parkinson’s Plus • AVM • Ruptured aneurysm • Seizure disorders

Working Census

• Between 20-25 at any given time • Average 10 patients per day • Waiting list X 6 months, average of 5 pts

Program Challenges

• Scheduling • Group Attendance • Staff Retention

Program Challenges: Scheduling

• Fixed supply • Variable demand • Coverage

Program Challenges: Scheduling

• Accommodating requests • Unrealistic expectations • Popular time slots are limited

Program Challenges: Group Attendance

• “Cherry picking” • No shows • Resistance to suggestion • Mixed population • Varied interests

Groups

• Cooking • Crafts • Tai chi • Meditation • Yoga • Coping skills/support

Program Challenges: Staff Retention

• Internal vs. external culture • Opportunity for growth • Demand for flexibility • Pay scale • Infrastructure

Challenging Cases: KJ

• 49 yr old MWF, athlete, high functioning, independent

• Highly motivated patient • Anxious family in functional denial

Challenging Cases: KJ

• Unreasonable or unrealistic expectations • Transportation • Breakdown in communication

What We Learned

• Pay now or pay later • Setting realistic expectations • Communication is key • People adapt to change over time

Challenging Cases: CH

• CH: older, WWF, retired, living independently

• Poor attendance, short notice changes • Unrealistic expectations

Challenging Cases: CH

• Concerns over HCP’s motives and intent • Suspicions reported to state • Family meeting: progress stressed • Withdrawal from treatment

What We Learned

• Advocacy can be uncomfortable • Try to find common ground • Protect the patient

Challenging Cases: PM

• PM: elderly, WWF, matriarch role • 3 adult sons • Entrenched family relationship dynamics

Challenging Cases: PM

• Lack of buy-in • No follow through at home • Dissonance about goals • Intra-family discord

What We Learned

• Our ability to influence longstanding family dynamics is limited

• Patient goals drive treatment • Meet patients and families where they are