What does the Continuum of Care Look Like in Brain Injury?

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The continuum of care for individuals who have sustained a brain injury refers to the coordinated system of services and support designed to meet their needs at different stages of their recovery journey. It's like a pathway or a journey map that outlines the various steps and services involved in helping someone with a brain injury get better.  

Disclaimer: Continuum of care may look a bit different for every individual dependent on their needs and what services are provided in the state/country. 

This marks the beginning of the continuum of care. It refers to the moment when the brain injury occurs, whether it's due to trauma, stroke, or another cause.

Traumatic and non-traumatic brain injuries can present very differently 

Immediately following the incident, emergency medical services come into play. EMS provides crucial on-site medical attention and transportation to a hospital for further evaluation and treatment. This is the acute care phase, where the primary goal is to stabilize the person and address any life-threatening issues. 

At the hospital, the injured person receives acute medical care. This phase focuses on addressing immediate concerns, such as controlling bleeding, managing swelling, and stabilizing vital signs. Imaging tests like CT scans or MRIs may be done to assess the extent of the brain injury.

*Some people may stay in Acute Care for an extended time due to not being “medically stable” for the next phase (rehab). Some examples of why a person may not be medically stable include: person being on a ventilator, cardiac problems, and many other reasons. In summary, medical stability is crucial before starting rehabilitation after a brain injury to ensure the safety and effectiveness of the rehabilitation process. Each individual's situation is unique, and medical clearance for rehabilitation should be determined on a case-by-case basis by the healthcare team overseeing their care.*

After the acute phase and once a patient is deemed “medically stable”, the individual may transition to a rehabilitation facility or program. Here, they receive specialized therapies aimed at restoring lost skills and functions. This includes physical therapy to improve mobility, occupational therapy to regain daily living skills, and speech therapy to address communication challenges.

Not every individual will qualify and be eligible for inpatient rehabilitation services. The reason for this is because an individual must be able to tolerate and actively participate in 3 hours of therapy a day. They must also warrant 24 hour supervision from doctors and nurses to be able to qualify. 

*Typical length of stay at an inpatient facility is 17 - 21 days. Length of stay will vary from patient to patient due to progress, discharge plan, and insurance.*

Of course the goal is to go home following the rehabilitation stage, but that may not be the best route for all individuals and their loved ones. Here are some examples of what discharge may look like…

1. Subacute Care:  A subacute can also be referenced as “SNF” or “Skilled Nursing Facility.”  A subacute will have specialized nursing care, therapy, and medical monitoring in a less acute setting than a hospital. Subacute care aims to continue stabilizing the person medically while preparing them for the next phase of the continuum of care. At a subacute facility patients will typically receive 1-2 hours of therapy a day. Nursing ratio will also look different, nursing has more patients assigned on their caseload. 

2. Outpatient Therapy: Outpatient therapy, sometimes called outpatient care, is when someone goes to a clinic or therapy center for their treatment instead of staying overnight at a hospital or rehabilitation facility. It's like going to a doctor's appointment, but instead of just seeing a doctor, you work with therapists like physical therapists, occupational therapists, or speech therapists to help you get better after a brain injury. You might go to outpatient therapy several times a week, depending on what your doctors and therapists recommend. After your therapy sessions, you can go back home and continue with your daily activities.

3. Home Health Care: Home health care is when medical professionals, like nurses or therapists, come to your house to provide care instead of you going to a clinic or hospital. They help with things like giving medications, changing bandages, or doing therapy exercises, all in the comfort of your own home. It's like bringing the hospital to you, so you can still get the care you need while staying in familiar surroundings.

4. Long-Term Care: In cases where the effects of the brain injury are long-lasting, individuals may require ongoing support and assistance with daily activities. This could involve receiving home health care services or accessing community-based programs tailored to their needs.

5. Community Support: Throughout the continuum of care, community resources and support groups continue to play a vital role. These resources help individuals with brain injuries reintegrate into their communities, access additional services as needed, and maintain a good quality of life beyond formal medical interventions.

To sum this all up…

Brain injury is a long road to recovery. Discharge plans vary for each individual based on factors such as their medical condition, family situation, insurance coverage, and level of support needed. While some may envision a seamless return home after a hospital stay, the reality is that discharge plans can differ significantly from person to person.

Factors like insurance coverage and available resources can influence the type and amount of support a person receives upon discharge. Additionally, family dynamics and the availability of caregivers play a crucial role in determining the most suitable discharge plan.

It's important to recognize that discharge plans may not always align perfectly with what individuals or their families envision. However, the overarching goal is to facilitate the individual's return home while ensuring they have the necessary support to be as independent as possible.

Ultimately, the discharge plan aims to empower the individual to thrive in their home environment while providing them with the assistance and resources they need to achieve their highest level of functioning. This may involve coordinating home health care services, outpatient therapy, medical equipment, and caregiver support to optimize the individual's independence and quality of life post-discharge.