Levels of Care

The medical community and rehabilitation care system of the Unties States for individuals with severe TBI is divided into several different levels. The levels of care are usually entered on a sequential basis, based upon the stage of recovery after the initial injury. The first six or so treatment settings-after acute inpatient rehabilitation-are common to many individuals with severe TBI. The rest, after acute rehabilitation, are highly variable from individual to individual depending on a number of factors; adequate funding being a major factor. On the following pages are short descriptions of the common levels of treatment care after TBI:

Emergency medical services - These individuals are trained in basic life-support and are usually the first persons on the scene of a severe accident. After severe TBI, the goal of these individuals is to sustain life, stabilize the individual's vital signs, as much as possible, and provide immediate and speedy transport to a hospital emergency room or designated trauma center.

Emergency room - Is where initial evaluation, stabilization, and treatment occurs. After severe TBI, an emergency, trauma, or neurosurgeon physician evaluates the individual and often will perform initial x-rays and CT scans to determine the extent of injury.

Surgery - Is where surgical operations are performed. After severe TBI, bleeding in the brain or skull fractures may be present and may require surgical repair.

Intensive care unit - Has the maximum nursing and physician direct care and management because of the unstable or critical condition present after most severe TBI's. This unit treats injuries, provides for adequate airway and nutrition, and prevents secondary infections and complications while the natural recovery process takes place. TBI patients are often provided with some basic sensory and physical stimulation to attempt to facilitate recovery.

Neurological unit - Is where the intensity of care is somewhat reduced but still is significant in the form of medical and nursing care. The individual may still be profoundly unconscious. Physical and occupational therapists now begin working with the TBI patient to provide passive range-of-motion exercises to prevent stiffening of the joints and atrophy of the muscles. When medically stable, the individual is usually transferred to a rehabilitation unit.

Acute inpatient rehabilitation unit - Care is transferred from neurosurgeons and or neurologists to a physiatrist, or specialist in physical medicine and acute rehabilitation. Acute inpatient rehabilitation utilizes a large, multidisciplinary team of therapists and nurses to facilitate physical and mental recovery from a severe TBI. This team includes rehabilitation nurses, physical therapists, occupational therapists, speech therapists, psychologists and neuropsychologists, social workers, case managers, recreational therapists, respiratory therapists, rehabilitation counselors, and vocational rehabilitation specialists.

Theoretically, treatment is continued in this program until significant progress is no longer being made. Treatment in acute rehabilitation may last from weeks to months. Discharge from acute rehabilitation can go in several different directions depending upon many factors.

Postacute residential facility - Is designed to provide residentially-based, 24-hour rehabilitation, improving cognitive, physical, emotional, and psychosocial abilities to facilitate better independent living skills. These facilities include treatment staff who are often non-licensed individuals called life-skills trainers or rehabilitation assistants, who provide "hands-on" daily training and assistance to clients in such programs. These facilities provide the full spectrum of clinical therapies, such as occupational therapy, physical therapy, speech therapy, counseling, etc. Treatment time can vary from weeks to years. Discharge is optimally made when the individual is ready to function in society with minimal assistance in activities of daily living, but this goal is often not met and continuing, sometimes lifetime, supportive services are needed.

Outpatient services - This is usually physical, occupational, and speech therapy with medical supervision done on a follow-up appointment basis after the individual is living at home. Psychological and vocational services are sometimes provided as well.

Day treatment - This is a type of service where the individual is given therapy and assistance throughout the day but lives at home. Treatment can vary from supportive therapy for severe impairments, to vocational training for higher functioning individuals.

Residential or home-based programs - Are designed to re-integrate the individual into the community. Such programs often include vocational assessment and training, as well as supported and competitive employment placements. The focus is on maximizing activities of daily living and vocational competitiveness.

Skilled nursing facility - Sometimes called SNF, provides continuing supportive nursing care augmented with some minimal physical, occupational, and speech therapy for severe brain injury deficits that are slowly improving or needing maintenance.

Residential nursing facility - A nursing care home with nursing services but usually no therapists on staff.

Home health care - The delivery of therapeutic and nursing services into the home, through specialized agencies.

Home - Being maintained and supported at home, usually by family members, with no ongoing professional support.

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