Welcome to part two of the Central Nervous System Transitions and Care. Tonight, we're going to be talking about the neurorehab journey through different settings in healthcare. So just, I'm going to give some quick introductions. I'm Dr. Fusco, my Assistant Professor of Rehab Medicine at NYU Langone-Rusk. We're also going to be joined by Dr. Marilyn Pacheco, Chief of Rehab Service at Edward Hines VA Hospital, and Dr. David Ripley, MD, MS, CRC, and faculty of AAPMNR, Associate Professor of Rehab Medicine, Feinberg School of Medicine, Section Chief at the Shirley Ryan Ability Lab in Chicago. Just some quick housekeeping. We are recording this webcast. Please mute your mic when you're not speaking. Please make use of the raise hand function or the chat function. Our moderators, we will be checking that closely. And obviously, you may ask the presenter's question using the chat function or raising your hand to be unmuted. And we're here to support you. So if you have any tech issues, just reach out via chat. Disclosure statement in compliance with the ACGME standards for commercial support of CME activities. We have no relevant financial relationships to disclose. So our agenda and objectives, our purpose of this lecture is really to understand the role of PMNR across various settings and the different types of settings. And Dr. Ripley is going to open with that. We're going to hear from Dr. Pacheco regarding the VA experience and discussing how this kind of transitioning care is done in the VA settings for patients with brain injury. And then I'm going to later discuss the process and challenges of transitioning care from one setting to the other and also the role of the physiatrist. And then we'll move on to our business meeting. So I'm going to turn it over to Dr. Ripley at this point. Thanks, Heidi. Give me just a minute and let me get this teed up and rolling. As Heidi said, we have no relevant relationships or conflicts to disclose. In my part of this discussion presentation, I'm going to describe the different settings of rehabilitation, where rehabilitation services are provided, and outline the differences between the different health care settings, and then discuss trends and provision of neuro rehabilitation care and potential threats and opportunities in the system. I will preface all of my statements by acknowledging that my bias is as a brain injury medicine physician. I do think that there are generalities that apply to all neuro rehabilitation cases, but a lot of the information that I'm presenting is based on the care of a brain injury patient. But I think some of the main points are still applicable, regardless of what diagnosis we're talking about. So just to start, this is a slide from a relatively old presentation that was really based on what a comprehensive system of care for traumatic brain injury looks like. The arrows actually represent the volume of expected movement from one setting to another. So initially, as you can see, there's an emergency response with transfer to an acute care trauma center. Of course, there's transfer within the acute care trauma center from the emergency department to neuro ICU to generally the med surge ward. And then the kind of a typical expected transition of care for neuro trauma is that then a patient would leave the trauma center and go to acute inpatient rehab, and stay there for a period of time and ultimately with a discharge home with some sort of follow up outpatient therapy. And that's what the bold arrows represent. Some about 15, 20 years ago, we noticed in our practice that there seemed to be a shift in where patients were going between these settings. And predominantly, we were seeing a greater transfer of patients to LTAC, long term acute care hospitals, without transfer directly to acute inpatient rehabilitation. Some of this was actually very appropriate. Many patients who needed, for instance, prolonged ventilator management or couldn't participate in rehabilitation due to other medical issues, needed to go to a different setting. And that's what the LTAC setting was designed for, for providing that level of care. The concern, of course, was that sometimes patients would go to the LTAC and then be transferred to another setting and miss the patient that would then miss out on the opportunity for inpatient rehabilitation. So one of the things that our group did at that time was start providing consultation services in some LTACs to try to, number one, provide care for those patients and make sure that they were really appropriate, properly teed up for inpatient rehab when the time came, but also as sort of a way to track how patients were flowing through the system and make sure that they were, you know, flowing to inpatient rehab to make sure they were getting their needs met. Other settings have also been, you know, fairly well seen. Transitional living programs popped up somewhat about probably 30 years ago, and they've become more prevalent. These predominantly are for brain and spinal cord injury, but the idea is these are programs that provide advanced level of rehabilitation care. And I'll talk more about these different settings a little bit later as we go through the presentation. So you see that the transitions between all these different settings has actually gotten really complex. And even after patients go home, there's still some complexity and transfer with different levels of rehabilitation care provided when a patient's in the home setting. So HHC stands for home health care. A lot of times when patients first go home, they still need therapy setting services in the home. It's very appropriate. We'll talk about that in a minute. Many rehab centers developed rehabilitation day programs, and I'll talk about the reason for that, and then, you know, traditional single service outpatient therapy and so forth with vocational rehab also were developed. Now, skilled nursing facilities have been around, you know, for a long time, and the way that rehabilitation services are provided in these facilities has actually evolved and changed over time. So I'm going to discuss some of the implications for what is the difference between these different settings. Admittedly, some of this stuff will be really well, most of the participants here will be really well versed, particularly with the inpatient rehab setting. But there may be some things that we talk about that is information you may not know. Okay, so the slide before that we just looked at kind of reflects that referral patterns have changed for neurotrauma patients over the last two decades, and this is in response to a number of pressures. Of course, the big one is funding. Other pressures include changes in demographics of our patient population, changes in care models, including changes in the criteria for admission to these different settings. I'm going to talk about that real quick. And additionally, changes in injury characteristics. With respect to funding pressures, this is no surprise to anyone. This graph represents the change in health care costs in the United States between 2008 and 2018. And you can see that on the very far left column, total health care expenditures went from a little over two trillion dollars in 2008 to a little over three trillion dollars in 2018. And this represents an average of a 4.4 percent increase in expenditures per year over that period of time. During that time, changes in length of stay in acute care hospitals for brain injury decreased by 3.65 days or 8 percent annually. So you can see that the response to increasing health care costs is often to decrease lengths of stay with the idea that that actually decreases the overall costs. Demographic pressures have also been resulting in some of these changes. The population is aging, so we have an older population with neurotrauma. There is also some positive things with changes in the availability of additional services per health care policy. This is usually state driven with things like brain injury, waivers, other waiver programs and so forth, other services that may be available. Care related pressures also are changing. Individuals are surviving because of advances in health care. They're advancing much more serious injuries than they used to. So this means that there are more complex patients and more complex care needed for more seriously injured and ill people. So some of this is a response to advances in good quality care. But the end result is that the patients that need our services are becoming more complex and they're more seriously injured. So some of the rehabilitation facilities that are the facilities that rehabilitation settings are provided are listed here. I actually borrowed this slide from Heidi, and so she may talk a little bit more about this in her section. But these are the description, kind of basic description of these different settings. So inpatient acute rehabilitation, which most PM&R doctors who do neuro rehabilitation work in. These are either freestanding or in a hospital within a hospital setting. In order to basically qualify, a patient must be medically stable, able to tolerate three hours of therapy per day, require at least two disciplines of therapy, average length of stay is expected to be 14 to 30 days. Then the next setting often described as subacute rehabilitation, which is really rehabilitation or therapy services in a skilled nursing facility. This is either an inpatient setting, but it is outside of a hospital. These are usually freestanding facilities. These patients must be medically stable. They must require at least two of the therapy disciplines. Average length of stay is longer because the intensity of therapy is not as high. Long term acute care hospitals or LTACs. These are patients with medical complications that require ongoing pulmonary and cardiac support. Length of stay there should be greater than 25 days on average for the LTAC setting. And I'll talk about how LTACs evolved a little bit later. Other settings include home health care. This is receiving therapy, hopefully in a coordinated team based fashion in the home. Then day treatment or community based services, which I would lump in here, community reintegration programs. I'm going to talk about these. Then just typical outpatient rehabilitation. These are patients that are receiving single service out therapy that may or may not have physician oversight in that setting. Post acute residential programs. Usually these are for patients who require ongoing monitoring or supervision for cognitive behavioral support. So let's talk about the criteria for inpatient rehabilitation. As most of you know, there are specific criteria. CMS or Centers for Medicare Services clarified these coverage criteria in 2010 and again more recently in 2018. For an inpatient rehabilitation claim to be considered reasonable and necessary, there must be the following requirements. One is that the patient requires therapy in at least two different disciplines. PT, one of which must be PT or OT, but it could be PT OT in speech or PT in speech, etc. The patient also generally requires to be expected to reasonably and actively participate and benefit from intensive rehabilitation. Now, here's where the wording gets a little funny. Most typically consists of three hours of therapy a day, at least five days a week. This is called the three hour rule. And I'm going to talk a little bit more about this extensively in a second. The other requirement is the patient is reasonably medically stable so that they can actively participate. The patient requires supervision by a rehab physician. The physician must see the patient at least three days a week. And then additionally, 60 percent of Medicare beneficiaries that are discharged from a particular inpatient rehab facility must have one of 13 conditions that qualify. If the facility does not meet this criteria, i.e., if they do not have a 60 percent discharge of one of these diagnoses, they risk losing their inpatient rehab status. Just real quickly, here are their conditions, stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, hip fracture, brain injury, neurological conditions, burns in arthritic conditions, as well as conditionally hip or knee replacement when it's bilateral or when the patient's body mass index is greater than equal to 50 or when the patient is 85 or older. OK, so let's talk about the three hour rule for a minute. I recommend, if you can, there was a recent article published by Miller and Forer in our journal PM&R talking about the history of the three hour rule. It's a really good article that summarizes all this history, and it's really fascinating what misperceptions there are about the three hour rule. Essentially, this was first discussed in a meeting between a committee that was organized by AAPM&R in 1978 in collaboration with the Peer Standards Review Organization, which was a predecessor of CMS, to come up with criteria for admission to the rehab unit. The main reason for discussing three hours was as an example for the expected intensity of therapy services in the rehab setting. There was never any studies actually looking at the effectiveness or validity of three hours as criteria. It was just really given as an example of the intensity of therapy. Now, subsequently, there were a number of studies that have looked at the three hours of therapy in different patient populations. There are several in particular that are quoted in stroke, but the results of the three hour therapy has actually met with very mixed results. Some studies actually find that there was a significant difference in three hours of therapy versus those that didn't, and some studies find that there hasn't been. There was actually a landmark case in 1989 where a patient was declined or denied payment for inpatient rehabilitation services because it was found on review that the patient didn't receive three hours of therapy. Now, this made its way through the court system, and ultimately, the judge ruled that a three hour rule can only be used as a screen for the reviewers, but not as a final determinant for payment of services. So look this law up, because this may be helpful if you have to argue for a denial of services by a Medicare patient that didn't meet the three hour rule. The first actual discussion of the three hour rule by CMS was actually in 2010, in the final rule of PPS to demonstrate the typical intensity of therapy typically provided in IRF. So in more recently, the statements by the CMS about the three hour rule was, this was supposedly clarified in 2018 with more recent guidelines that, quote, although it may be common for denials to be based on hours or minutes of therapy time a patient receives, the law actually states that the reviewer shall use clinical judgment to determine the medical necessity of the intensive rehabilitation therapy program based on the individual acts and circumstances of the case, and not on the basis of any threshold of therapy time. I.e., they're supposed to look at other factors like the function of the rehabilitation team, physician oversight, were there medical complications, et cetera, and so forth. Now, most recently, the CARES Act, this is a response to the coronavirus pandemic, has waived the three hour rule requirements for IRFs. I'm not sure if this has ended yet or not, but according to the response to the coronavirus, the requirement for three hour rule was relaxed for discharge of patients during the COVID pandemic. So what are some of the other trends for inpatient rehabilitation? In 2013, $6.8 billion were spent on fee for service inpatient rehabilitation care by Medicare. Medicare accounts for about two thirds of all inpatient rehab discharges. There are 1160 inpatient rehab facilities nationwide. The average occupancy is about 63 percent. In addition, there have been some other trends over two lengths of time from 1990 to 1996. This was a study our group did at Virginia Commonwealth University. We looked at charges and length of stay in both acute care and rehabilitation hospitals for traumatic brain injury. We showed that hospital lengths of stay decreased and inpatient rehab lengths of stay decreased about 8% annually. Following that, there was another study done by Chu and Lercher and Archives of PM&R just published last year showing a different time period from 2010 to 2017. Lengths of stay in TBI model systems decreased from 27 to 23 days. In the same period of time, discharges to skilled nursing facilities increased and about 27.8% of patients were re-hospitalized, which was an increase. What we're seeing with trends from IRF care is decreased lengths of stay with associated increased re-hospitalizations and increased discharges to other facilities other than the community. Currently, according to CMS, average length of stay for inpatient rehabilitation for brain injuries is about 17 days. Over the same period of time, as I mentioned before, cases admitted to inpatient rehabilitation have increased in complexity. Some other trends. In 2004, CMS began cracking down on the case mix index. As a result, there was an 82% growth in admissions of patients with neurological disorders to inpatient rehab facilities, even though the total number of Medicare cases declined 24%. This is good for us as neurorehabilitation professionals in that the population is shifting to more of a neurorehab basis, but there's still some other threats. According to the PPS system, the per case costs have continued to increase. This graph is from a report to Congress, I believe it was 2013. But at the same time, the cost per case, the payment per case has increased cumulatively more than cost. The risk for this is that CMS will continue to look for new ways to contain costs. One of the biggest things is this concept of site neutral payment. This keeps popping up every so often. Most recently, it was in the budget proposal for the 2021 budget by the Trump administration. Essentially what this says is that they're going to level the playing field so that they'll provide a single lump payment regardless of the site that rehabilitation services are provided, whether that be SNFs or IRFs or potentially LTACs, thinking that this is going to ultimately end up in saving costs. Now, there have been a number of rebuttals to this, and fortunately, so far, this has been staved off. Just putting this out there is a big risk to business as usual and why things are changing. Let's talk about some of the facilities other than IRFs. Let's talk about LTAC. Historically, LTACs evolved as sites for patients to receive care when they needed prolonged ventilator care. Most of them were really designed to be ventilator care hospitals where the patients were essentially stabilized on a ventilator in an acute care hospital, and they needed a place to go because they couldn't stay in the acute care setting for that long. These can be either freestanding or be a hospital within a hospital. To qualify as LTAC, the patients must meet certain criteria. The patients must have an average length of stay of greater than 25 days. The patients must require daily physician intervention to manage multiple acute complex medical needs, which can't be managed at a lower level of care, and they must meet certain medical criteria. For instance, ventilator weaning, complex wound care, cardiac monitoring, the need for prolonged or multiple IV therapies, and monitoring for significant medically active conditions, needing an assessment six or more times a day. In addition, if there's a need for specialized on-site high-tech equipment, such as dialysis, that's a criteria, and comprehensive rehabilitation is thrown in there as an additional criteria. In 2016, Medicare payments to LTACs were $5.1 billion. From 2002 to 2013, Medicare paid LTACs based on a diagnosis and market area wages, so the actual funding that an LTAC would receive was kind of based on where the LTAC was located and what the wages in the environment that it was based on. LTACs were also assigned to case-mix groups of patients with similar clinical problems that were expected to require similar resources. In 2013, they developed this dual payment system, and they'll talk about site-neutral payment. This was one of the new things that tried to level the playing field so that LTACs in one environment weren't at a disadvantage to LTACs in a different environment based on the wage information. So that was when you talk about site-neutral payment in LTACs, that's generally what you're talking about. One other thing to know about LTACs is they receive one payment for interrupted stay patients who are discharged from a maximum time to another setting and returned to LTAC. The maximum time can be nine days for a patient that has to go to an acute care hospital, 27 days for IRF, or 45 days for a SNF. If the patient stays in the other setting for less than three days, the LTAC is responsible for paying for the services provided by the intervening facility. So you can see that an LTAC who discharges a patient to another setting will be incentivized to make sure that they don't need the patient to come back right away, otherwise they get hit with some of the costs. Skilled nursing facilities are another setting. This is often referred to as subacute rehabilitation. However, just to point out, there really is no such license or criteria or CMS category as subacute rehabilitation. This generally refers to therapy services that are being provided in a skilled nursing facility. Typically, a patient in a skilled nursing facility who's receiving rehab will receive 30 to 90 minutes of therapy, usually three days per week. A length of stay in the facility is usually longer, 60 to 90 days. There are really no rules on therapy provision, but this is just typical. Many skilled nursing facilities will outsource rehab services. There's no requirement for rehab physician oversight. There's no requirement for an interdisciplinary team approach. However, no real rules actually represent a potential opportunity. You can provide, there's no rule that says you can't provide three hours of therapy in a skilled nursing facility. Most skilled nursing facilities are not set up financially to be able to afford to provide that much therapy. However, many new PM&R group models are using this opportunity. In particular, there's one very well-known national, it's considered the largest PM&R group practice, I think, in the world, and their business model is to provide PM&R physician staffing to skilled nursing facilities, because if they're ordering therapy services, then the facility can actually charge more for that patient. The physicians actually get to staff the patients, take care of them, and usually this is a win-win for the patients as well, because they're getting better therapy services, and ultimately they're getting improved care. It's kind of a win-win all the way around. Another setting is day rehabilitation programs. This evolved out of the need for continued rehabilitation from pressures to reduce length of stay in inpatient rehabilitation. The model is to provide the same interdisciplinary therapy approach as inpatient, but in an outpatient setting. Most of these will have a PM&R physician on site who will see patients intermittently, usually not weekly, but definitely on admission, and then occasionally while they're in the program. Usually they do team conference, like inpatient, and the PM&R physician will be active and participate in that. Generally, they'll have all therapy disciplines, as well as a social worker, nursing, and many will have psychology and vocational rehabilitation on site too, so it really is modeled after inpatient rehab, but the patient will go home. The opportunity to provide many rehabilitation services is not possible in IRF. That or not possible in IRF or available in a day rehab program, such as visits to banks and other vocational rehab services and efforts, just because of the type of patient that's in there. There's less pressure on patients to make functional progress within a set period of time. In order to qualify for inpatient rehab, you have to demonstrate functional progress, usually week by week. However, for a day rehab program, this does require a family or social support to provide care for the patient outside of the therapy time, and they're generally not set up for more medically complex situations, such as patients receiving IV infusions or wound care. Another setting is home health therapy. This is single-service therapy generally provided in a home care setting. In order to receive home health care therapy, a patient must be considered homebound by CMS. I've actually personally had patients get denied home health care therapy because CMS found out that the patient was able to go to activities outside the home. Home health therapy does not provide custodial or attendant care. This actually must be paid for separately, so the family must be able to provide care outside of therapy time. They may or may not have a case manager or nurse, if a documented need exists. Often it's not approved unless it's used immediately after a hospital stay, so this is often helpful for transitions home when the care routine is complex. I actually love to use home health care when the patient's actual setting in their home needs to be set up for generalizability and continued care, having a therapist actually in there setting up their bathroom right or the kitchen right for the patient is very helpful. Post-acute rehabilitation programs, this is another setting. They often have different names, such as community integration, transitional living programs. These are traditionally used for TBI or SCI. I have known some exceptions where stroke patients and other neurotrauma patients will go. These are usually either a campus or a home type setting. The patients have 24 hour a day onsite supervision, and they will go to a single therapy site during the day. The therapy that they receive there can actually be at times more intense than a typical rehabilitation day program. They often do some really interesting neat activities that often are not available in a day program. Other types of settings that are honorable mentions, I would mention assisted living facilities. This is more long-term care. Some of these actually provide more intense therapy or other services needed, but generally this is when a patient is stabilized and really ready to kind of be stable in their care. In clubhouse model, these are vocationally based programs, practice return to work skills. Usually these are programs run by the patients with staff supervision and guidance. I'm going to go back to the original slide here with the flow. You can see that the flow between all of these different settings has actually become quite complex. My opinion is that over time, the need for physiatrists to be present in all of these different settings is going to increase over time. It is actually necessary to make sure that the patients are receiving the adequate rehabilitation services. So I think the trend will be in the future to see more and more PM&R docs practicing in consultation roles in these different settings and not just based in an inpatient rehab facility. And that ends my section. I'm going to stop sharing slides and turn it over to Marilyn. Let me share my screen. Okay. Good evening. I'm Dr. Marilyn Pacheco. I'm at Hines, Edward Hines Junior VA Hospital. And I'm going to be talking about navigating the different levels of care in the Veteran Health Administration. So most people like in the VA, it's a lot of the common term is like one VA. So we all are in the VA system to care for him who shall have borne the battle and for his widow and his orphan by President Lincoln. So the objectives of this study, this presentation is to get acquainted with the Veteran Health Administration, especially for those that are out in university practice, private practice, different levels of care outside the VA, understand the different levels of care in the VA, identify the polytrauma TBI system of care and identify the SCI system of care. VA is the largest healthcare network in the United States. We have about 1,243 healthcare facilities. And among them is 172 VA medical centers and 1,062 outpatient sites with varying purposes. And we are divided based on geographic location into 18 veteran integrated service network. This is VA likes, we like our acronym in the VA. So this is called the VISN. And we are under the Secretary of Veteran Health's Affair for Health. And it got changed a few years, like, you know, 20 something years ago, the department, it became a Department of Veterans Affair. Under the Department of Veterans Affair, we have Veteran Health Administration, Veteran Benefits Administration, and the National Cemetery Administration. VA hospital setting, it's typical kind of like a usual hospital, we have ED, we have acute care, and then we have different next level of care. But I will not all VA have all of this, it depends on the type of VA that you're in. In my VA, we have all of this because we are called the 1A facility. And I'll talk about that a little bit later on. So we have MICUSICU, Step Down Gen Med, Gen Surge Floors, we have PACU, I was the medical director of an acute inpatient rehabilitation unit. And then aside from PM&R and rehab service, we have also SCI centers. There's also transitional care unit, which is in the hospital. And then we also have, we have subacute rehab there. And then we also have community living centers or extended care centers, wherein we have subacute rehab, hospice, palliative, respite care, wound care, antibiotic care. We do not have LTAC in my particular VA. But I don't, I haven't heard, don't quote me, I don't know every VA, even though it's supposed to be one VA. I don't know about LTAC system. So in our outpatient setting, we have, we have something called CBOX. This is the community based outpatient clinics. And then we have community service programs. We have vet centers, we have domiciliary care centers. And then we have our own VA outpatient clinics within the VA hospital setting. So this is what I'm talking about, about the VHA facility complexity model. I am in the highest complexity, Edward Hines is 1A. So just an example within my VISN, I am in VISN 12. So we have actually three VAs in the Chicagoland area. Hines is the 1A. And then we are located in Hines, Illinois, which is a suburb near Chicago. We have Jesse Brown VA, which is in Chicago, and it is a 1B facility. And then we also have one of the unique VA is one that is associated with a federal component, which is the Navy, which is our North Chicago VA, it's a Captain Lovell VA, which is a 1C. And then within our VISN, we have also Milwaukee, which is a 1A, and then different types, Madison is 1B. And then we have Toma, we have Danville, which are like two and three in their complexity levels. Going back with the complexity level is, you know, the 1A complexity level is the largest levels of volume patient risk teaching and then research. We also have the largest number of physician specialists. And then 1A facilities also have like the ICUs, the intensive cares and things like that. And then 1B also have ICUs, but it just depends on the different, but then I don't, they don't have some of the specialty surgeons, like we have the neurosurgeon and then we get all the referrals from the other VAs around us. So I'm going to talk about the polytrauma TBI system of care. This for polytrauma system of care, we have the top on the section is the polytrauma rehab center. And these are the regional referral centers for acute inpatient medical and rehabilitation. And then we under that is the poly network site, polytrauma network site, which provides post acute rehabilitation and coordinates polytrauma services within the VISN. And then under that is the polytrauma support clinic teams. And these provide outpatient interdisciplinary rehab evaluation and treatment services within the catchment area. And then we have polytrauma point of contact. And this is at each VA facility that delivers a more limited range of rehabilitation services and facilitate referrals to the other polytrauma support clinics or even to the the polytrauma network site. In here, this is how it is set up. This is the VA polytrauma TBI system of care. And as you can see, the polytrauma rehab center, we have Palo Alto, San Antonio, Minneapolis, Richmond and Tampa. Hines that where I'm at, we are the poly network site. And then there's several network sites across the country. And then then we have the support clinic team, which are all the green dots in the map. And then the polytrauma point of contact, which are the purple dots. We also have one in Hawaii, one in the Philippines, one in Alaska, and we have a network site in San Juan, Puerto Rico. So the PRCs, they are like the acute medical center, we have a rehabilitation care, they are the hubs for research education that is related to polytrauma and TBI. They provide continuum of rehabilitation service. So they have the most funding, and they provide specialized emergence of consciousness programs, comprehensive acute rehabilitation care for complex and severe polytrauma injuries. They have outpatient programs, assisted technology evaluation and training, and they have something called the P-TRIP. This is the residential transitional rehab programs. In my site, we provide post-acute rehabilitation for veterans. So we do have I when I was a medical director, we do take the TBI centers because we want to keep the patients near home. So we do take them and then take care of them. And then we have also the TBI for outpatient in in Heinz, which is the network, the network site. And then we provide care for all the TBIs within our catchment area. And so we have inpatient rehab for those transitioning closer to home, comprehensive outpatient TBI evaluations, a full range of outpatient therapies, evaluation for any durable medical equipment, and assisted technology. And we actually have a very cool, like we have a rehab engineer and included in he is in charge of our assisted technology. We have access to other consultative specialists and follow up care and case management. And we try to connect each patient to their primary care physicians at the end of their stay in rehab. And then we do have the outpatient that we do continue. So there's a continuum of care. So let's see, time wise. And so P-TRIP is special, like in terms of there's five P-TRIP program. And P-TRIP is different, like from the transitional rehab programs from the outside. When I visited Minneapolis, which is one of the things about VA, we get to visit different VAs to see each site's services. And these type of that P-TRIP is very unique for me coming from the outside world into the VA. I've been in the VA for almost 10 years. And it's interesting because these are patients that are independent, trying to transition to like work and things and they get to stay in a unit inpatient. And then they are very independent maneuvering around the VA hospital. And then so this is just one of the things that are special in terms of the services that's provided in the VA. Another thing that I thought that was unique is the emergence of emergence of consciousness program in typically when I have a, you know, Rancho 1 type patient or Rancho 2 within my catchment area, which even though I'm the network site and can take care of TBI, but for emergence of consciousness, like those that has disorders of consciousness type patients, level one, level two, we could arrange patients and talk to Minnesota to look at our patients and then transition them to get them to Minnesota. And they have quite a team over there that could take care of patients emerging from coma. Then we have the after the acute care, trying to recover and those that are unable to go home, we try to get them to the different assisted living, and then medical foster homes and then nursing home care. The assisted living we work with private assisted living or, or, and then or independent living if they're getting to independence, but can't like manage home anymore. We do have something called medical foster home for patients can go to I have sent not my TBI patients, but a lot of my stroke patients have used this medical foster home. And then there's a nursing home care. In the VA, we have our own nursing home, which is the extended care or the community living center if but there are limitations in who can get into those to that facility. If they're not, mostly it's what we call service connected. If they have their injuries or their problems related to while they're in their service. If not, then we could set up a community care nursing home for them and that can be paid for by the VA. Then I'm going to talk about spinal cord injuries, this order system of care. This is made out of hub and spokes. And the hubs are the blue and the spokes are all these other areas. So the hubs, there are 25 hubs in California, there are three Colorado, Florida, Georgia, Illinois is a hub. That means we have SCI centers in these VA facility, which in that they, this are different from the spokes, the spokes are more mainly out like they work closely with the SCI centers. And they are located around the country, they provide healthcare providers, primary care specialized needs, it's these are more outpatient, they do not have the inpatient part. In the inpatient part, they have what we call the rehab part. And then we have also this, the ones that come in for chronic care. So we are the in some centers, we are the primary care providers for all the spinal cord injury in some centers. They have primary care and then they have their physiatrist, it just depends on how it is set up in each center. I was fortunate enough that I am now at Heinz and then I also work in Dallas wherein we have our own SCI center there. And then you know, people I've known all over, shout out to like people in Florida and also in Virginia and in Augusta. So I have, I know people all over because of the different kinds of the way that we collaborate within the VA. Okay. So in how do you know that you're the patients are eligible and for enrollment, there are two questions for the SCI. Because this is how you get in, right? The two question is, do you have a spinal cord injury or disorders? If that, and then were you ever in the military? If both questions are answered, yes, then they could contact the SCI center or contact VA and apply for their healthcare benefits. It doesn't mean that they're, you know, just because their injuries are after their service doesn't mean that they cannot, because they are veteran, they can still come to the VA for care. So these are like the full range, which is all traumatic spinal cord injuries due to events of motor vehicle accidents, falls and acts of violence, atraumatic non-progressive etiologies of spinal cord disorders. And then it has to be stable, of course, to get in. And then the primary problem is related to spinal cord disorder opposed to brain than peripheral nerve. When there's brain and peripheral nerve, they tend to come to us in the PMNR world. And then resultant sequelae should be sequelae should are clinically and functionally significant, thereby resulting in impairments in mobility, activities of daily living and visceral function like bowel and bladder and any level of spinal cord injury, including the conus and cauda equina is involved. They have to, these are some illustrative examples of populations serve for veterans, like we can have neoplasms, multiple sclerosis also, as long as they have spinal cord involvement. But if they have mainly brain involvement, the rehabilitation service comes in. And then myelopathy, secondary to nucleus pulposus, spinal stenosis, any myelopathy, they can seek eligibility at the SCI centers, AV malformation, and then epidural abscess and other vascular inflammatory and infectious resulting in a significant myelopathy. And then the exceptions are, you know, if they're from intracranial or peripheral nerve disorders, even though they are, you know, they have tetraplegia or paraplegia, conversion disorders, they don't go to the SCI. MS that is again, not of spinal cord origin. So these are not the ones that would go to SCI. So they have, they do review this. And there's a reviewer for this types of it for the eligibility. And then SCI and benefits, you know, there's also other things that we work with for their compensation and pension, higher aid and attendance for those who require daily skilled care, car grants, adaptive equipment for their cars, home grants, clothing allowance, educational benefits. HISA program is a home program for like home improvement. Like most veterans have a HISA they can have an HISA one in a lifetime to fix their typically what is being fixed is like their bathroom because wheelchairs can fit, adaptive equipment can fit in there. And then there is a life insurance premium waivers that can can be given. The process of referral is still like from the outside if you have a veteran that wants to come in is especially for acute care or any acute care is through the acute care transfer office. And then typically what happens is if like some, I review a lot of this because they want to come in for acute inpatient rehab. And then we get the notes as long as the notes are complete and timely, then we were able to like answer it in an appropriate time. Sometimes we get, you know, all these referrals at the last minute, thinking that they could transfer right away. There are other things that they have to look at is the eligibility of the veteran. Are they qualified for veteran care like VA care? There are some that are dishonorably discharged, so that might be a problem. Well, while there are those that are, but that's very rare. In the 10 years I have probably like two that I accepted and turns out they're not eligible for care because it wasn't like just the checking of things. And then, you know, it's reviewed by one of the physiatrists and then we'll recommend the different levels of care between acute to subacute. Sometimes if they're not medically ready, then they can go through lateral transfer to acute care. And then sometimes if they're more like stable and it's more a nursing home, then we do collaborate with the geriatrician who's running the CLCs or the nursing home and they can review that. So those are the types of different ways of navigating into the VA. So I hope that's the end of my talk and I will transition this to Dr. Heidi Fusco. And then we'll talk about questions later on. I will end my slide and stop sharing at this point. Thank you, everyone. Thank you, Marilyn and Dr. Ripley for those talks. So I'm going to transition back to our patients kind of transitioning care from one setting to the next. We're going to, I'm actually going to talk about the challenges endured by patients. And I guess just kind of guys cut me off when we need to transition to the business meeting. I'm going to discuss the importance of coordinated transition in the role of the physiatrist. So just to scope of the problem, what we're dealing with, stroke is a leading cause of death and disability in the US. Almost 800,000 people have a stroke each year in the US. One in six cardiovascular deaths is due to, or one in six deaths is due to stroke in 2018 from the CDC. Including in brain injury, we have TBI. There were 61,000 TBI related deaths in 2019. And as Dr. Ripley had mentioned, the population is aging. TBA related hospitalizations per 100,000 people are highest in adults aged greater than 75. And then the next group would be adults 65 to 74. And then the next group would be 55 to 64. And this data is, is from 2016, 2017. The trends that we're seeing are that rehab lengths of stay are steadily increasing, decreasing. And this includes inpatient rehab and SAR. Patients are coming to inpatient rehab and SAR with greater impairments and medical complexities at admission. And they are being discharged with greater impairments and medical complexities. The population is aging. Older patients have poorer outcomes. And we really need to prepare and expect that there are going to be more elderly people in need of quality rehab. What we're seeing is a notable increase in institutional discharges. That means patients are leaving hospitals and acute care centers and going to subacutes, LTACs, and SNFs. The risk factors for patients not going home is advancing age, like we keep mentioning, and this number is going to continue to get worse. Living alone prior to injury, patients still in post-traumatic amnesia, which is a period after a severe traumatic brain injury, or any kind of brain injury, unable to follow one-step commands and greater assistance for ADLs and functional activities. Kind of one thing that's concerning to me, since patients are now staying in acute rehabs 12 to 14 days, patients have these sequelae after brain injury, which includes spasticity, behavioral issues. They're having recurrent CBAs, recurrent TBIs. They're having stroke and TBI-specific cognitive impairments that are unique to a stroke and TBI or a brain injury, and that they improve. This isn't dementia we're dealing with. This is a degenerative condition. And often, patients kind of moved out of a recognized brain injury center may be lumped into a degenerative condition, and that is problematic. We have hydrocephalus and seizures, sleep disorders, infection, DBT, polypharmacy, the list goes on. But who is managing this if they're, you know, not under the care of a physiatrist in acute inpatient rehab? Dr. Ripley, you know, mentioned all of this. So I just wanted to kind of throw back up there so you can see it. You know, this is where this sequela of these brain injuries needs to be managed, whether it's acute inpatient rehab, where, you know, we're all there and we're all managing it, or maybe there's not a physiatrist present at these locations. So the clinician's role, kind of, you know, what do we do during the inpatient? How do we fix this? Well, we got to stabilize the patient. We have to educate the patient and their family about the prognosis, the recovery process, the medications, the treatment options. I actually took this picture at my niece's elementary school yesterday, change your words, change your mindset. You know, just kind of be careful. Patients don't understand what a brain injury is. They either overshoot or understand their understanding of it. They think the stroke, it may not affect, there can be a stroke, there can be bleeding, but it's not going to actually affect the brain tissue, which is incorrect. There is a great, you know, there's a significant event and process in the brain that has impaired that brain functioning. You know, they separate, okay, the brain is not bleeding, but there's blood in the brain. It's kind of a confused thing. Well, if they take the blood out, then the brain tissue is okay. Not the case, unfortunately. But also, there's kind of education on, you know, it's not brain damage, it's a brain injury. There is room for recovery. How the person looks now is not how they're going to look in a month from now, or, you know, we're hoping they look significantly better. They wouldn't be in rehab if they weren't going to look better. Family and cultural dynamics, always fun. We've got ex-boyfriends coming out of the picture trying to get patients to sign, you know, marriage papers, who knows what's going on. You want to manage realistic expectations. You want to develop an individualized treatment plan for that patient. Kind of recognize caregiver burden. It's very awkward to have a husband or wife, you know, managing bowel and bladder regimens for their spouse. And you really have to approach discharge planning on day one. And I tell my patients, this is why I'm calling you to talk about discharge planning. We do this on day one for every patient. It's not because I want them to leave tomorrow, but 10 to 14 days goes by in a blink of an eye. In the subacute role, you know, it's more drawn out. And it's wonderful if a physiatrist can get into these areas. Continue to provide education about the recovery process and the setbacks. Setbacks, again, change your words. That may occur, you know, I call them little bumps. You know, hydrocephalus is part of the recovery process. We just manage it. Avoid, it's not a setback. Avoid giving contraindicatory or inconsistent advice, you know, advice. You know, don't say, if you don't know, if you don't know or you don't have predictive answers of how a patient's going to do prognostically, you know, don't say it. I often have to deal with dealing with a family member saying, the surgeon said my loved one's going to be able to drive and be back to work in six months, you know, when they're in the minimally conscious state. Again, the individualized treatment plan, managing the sequela, all those sequela that we talked about, spasticity, pain, sleep disorders. Provide resources for the family member. Again, they're in this marathon of recovery. It's not a sprint. And identify and address gaps in the system of care. You know, saddle up next to surgeons that you can work with, good neurologists that you can work with that are going to help your patients in the subacute phase. So what happens after discharge in 2005? I'm just going to sum this up very quickly. Families are always happy at the care of acute rehab. After discharge, especially outside major metropolitan centers, there's a lack of, there's a lack of support. There's a lack of resources. There's, you know, patients are lost to follow up. Family members are isolated. They lose their, patients lose their social network. The patient's tired. This contributes to further isolation. There's headaches, there's aggression, there's impulsiveness, there's confusion. You know, aunts, uncles aren't coming over anymore. People stop coming around. And family members and clinicians become exhausted from trying to coordinate this care. People with brain injury and families feel socially isolated. There's a shortage of organized support services. And there's uncertainties about the prognosis and, you know, how they can continue on with us. So this is where we really need to kind of fix this up. And, you know, this little silly brain with a bandaid, but we really need to kind of address this. There's a honeymoon. Everyone's clapping and the patient's going home after a three-month stay. And then there's reality hits and it just slams them in the face at around, you know, the weekend's over and the wife has to go back to work and the home health aide doesn't show up. And, you know, there's an accident in the bed and it's just a nightmare. There's, we need to kind of address the coping with the changes in lifestyles and roles. You know, there's some intimacy, anger, personality changes, social life, to name a few. There's community re-entry issues. You know, the person can't go down to the local Rite Aid and buy, you know, soda anymore. Everything is, is may need, they may need help. They may need supervision. They need, may need help with money management. They may need 24-hour supervision so that they don't fall. Sorry. There's safety concerns, return to driving, work and compliance. And then there's always the issue of alcohol use, which always should be addressed with every patient. Again, where is, who's managing all these medical sequelae? And these are just a few of them. I'm so sorry. I'm in New York City and I have sirens everywhere and cats apparently. So the physiatrist role, you know, educate the patients and families about recovery processes in managing expectations and sequelae. And then we're not educating, we're enlisting our patients with the resource. We're, we're getting the patients to sign up for these resources. Whether we have a social worker or, you know, a psychologist helping us, or we're physically doing it ourselves. You know, we really have to address the gaps in care. So challenges and access in care. And again, Dr. Ripley talked about this limitations in insurance, you know, who's paying for whatever. I take all insurances, but my colleagues, you know, the ENT may not take Medicaid and that's a big problem. So I find someone who does, I need to find a urologist. Families aren't supporting the family, financial restraints, limited transportation. There's a lack of insurance coverage for home health services, lack of knowledge. So what can we do? Again, this is very quick and this is specific for New York City, New York State, Medicaid, charity care, SSDI, some of it applies nationally. Families, again, need to be educated. They forget, they don't remember maybe what you said three months ago, but what are the recovery expectations? What can they expect at this point? You know, and I always say past recovery is a predictor of future recovery. Estimated cost of home care, home health aid, you know, give them a realistic figure. You know, you say you're going to provide 24 hour care, you're going to hire somebody, but you don't realize it may cost three to $4,000 a week. There's the waiver, there's FMLA. Again, it's not paid. There's accessorize, able ride, Medicaid waiver library in New York City. There's support groups. Being mindful of the cost of all of this, you know, unless you have a long-term care plan, private paid, which are very expensive, or Medicaid, you may not be able to get 24 hour anything without bankrupting your family, and Dr. Ripley already spoke about this. So, in New York State, we have the waiver, and I know it's present in other places, but again, just really quick, you get a service coordinator. They have a structured day program, substance abuse programs, and again, you can enroll in this if you were less than, I believe, 65 when you sustained your brain injury. It used to just be for traumatic brain injury, but that includes all acquired brain injuries, and then you get a lot of support. Skipping through that, the problem, again, activation period, you could be in subacute waiting three to four months. If you have a place to go that is accessible, you may be waiting a year to a year and a half if you need accessible housing, and again, when you're in a coma, and you're in acute rehab, and your family's running around, and they're taking FMLA, people tend to lose their apartments. They lose their house. They lose things. I have a lot of patients, family members just kind of take their stuff, which is terrible. So, finally, I'm going to talk really quickly about access to something which is kind of unique, and this tele-rehab. We've heard of telemedicine. I haven't actually seen the word tele-rehabilitation in print, but I like this study because it was 2019. It was pre-COVID. COVID wasn't even thought about when this came out, and it talks about the efficacy of home-based tele-rehab versus in-clinic therapy for adults after stroke. It's a lovely randomized control. The assessors of the person were blinded. So, again, patients aren't getting adequate rehab due to transportation access issues. This happens to me all the time. I finally get them into speech and everything, you know, through the waiver, and suddenly, they can't get to the darn therapy. It's an hour and a half. Their library's cab doesn't show up. You know, they're missing all their appointments, and they get discharged, and they don't know any better, and the family may be going through some other things, too, and they can't always be there to accompany their loved one to these appointments. So, they compared the recovery of arm movement delivered via home-based tele-rehab versus in-clinic rehab. They had 124 patients across 11 U.S. sites post-stroke, 4 to 36 weeks, and they measured Fugl-Meyer scores. These patients all were 22 to 56, pretty impaired. They did interventions, 36 sessions, 70 minutes each of arm motor therapy plus stroke education with matched therapy intensity, duration, and frequency across both groups, and what they found was a significantly improved greater adherence in the tele-rehab patients versus the in-clinic therapy for the adults with stroke, and both groups made significant improvements, so it was good therapy regardless, and there were no difference in Fugl-Meyer gains, so it works. So, tele-rehab, not only you have better adherence, patients do it, they like doing it, and they were, you know, this was almost a year out from their stroke, 36 weeks, and they did well with that, just as well. So, thankfully, this carried on through COVID, and, you know, insurance pays for it, so don't disregard the idea of tele-rehab. So, take-home points. Patients have challenges in transitioning from one care to the next. Our education is of huge importance to the patient and family. You know, what is a brain injury? What do you expect from, what do you expect to recover? What are, what are, where is all the therapy taking place? What is available to you? Take advantage of all these resources, and, in fact, push them to do it because they don't realize, like, how important it is, you know, to get on SSDI or to get Medicaid. You know, it's a huge importance if you have a brain injury and you're young to tap into these services, but also what it means when you have this. Develop a care navigation pathway that's appropriate for each patient. Obviously, this same recommendation is not, is not appropriate for each patient, and then, you know, if you can partner with a good outpatient social worker and a good care team that can help, you know, you can delineate all of this education to them and make sure the patient gets plugged in and not just lost into the community. So, I'm going to exit now and stop sharing. Thank you. Thanks, Heidi. I don't know if we got a couple minutes if anybody has any questions. I see some comments that are up on the, on the chat box. I'm going to go ahead and move to the business meeting if there are no, no comments or questions. So, real quick, this is a business, our annual business meeting in lieu of the annual assembly this year. I'm the chair of the CNS member community, and now Dr. Kristen Caldera. I'm handing the proverbial baton, wand, to her to take over. She's, after this meeting, the chair of CNS member community. So, congratulations to Kristen and thanks. I'd like to real quickly mention our current officers. It's myself, Kristen Caldera is the current chair elect, now the actual chair. Cherry Jhun, vice chair of communication. Heidi Fusco is vice chair of membership, and Marilyn Pacheco, vice chair of education. Over the last year, we, achievements that we've accomplished over the last year, we've had three member community events, which has increased from last year having only one. Most of these are focused on the lifespan and transition of care for people with CNS injury and illness, based on recommendations from the CNS member community. We had our first conjoined session with pediatrics. I thought that went really well. It was kind of cool to have a conjoined session with another member community. I hope we can continue that kind of thing in the future. We added a new leadership committee position, vice chair for members in training, which I'll talk about in a minute, and mainly dealt with COVID-19, which interfered, I think, over the last couple of years with a lot of, we had some great ideas and plans that some of them just didn't pan out really, I think, in large part due to the pandemic and stresses and strains because of that. We just finished our elections for our new members. Our new chair elect is Diane Mortimer. She is at the VA Poly Trauma Center in Minneapolis. Our vice chair of communication is Dina Hassaballah. Dina Hassaballah is here at Shirley Ride Ability Lab temporarily. She's going to be moving to Seattle. The vice chair of members in training, our newest position, is Katie Eltonji, who is currently doing brain injury fellowship at JFK in New Jersey. Here's our new leadership committee going forward, as I mentioned, and looking forward to seeing great things that they're going to be able to do. At this point, I'm going to turn it over to Kristen and let her talk about plans for next year. To you, Kristen. Thank you. Thank you for that introduction. Again, I am Kristen Caldera, and I've had the privilege to work with Dr. Ripley for the last two years on the CNS community. Just over two years ago, I heard that AAPM&R was creating more communities and really soliciting people to be more involved and be a part of AAPM&R. I felt like CNS was a really nice home for me to start in because I work with a lot of those different patients, whether it's stroke or TBI or MS or adults with developmental disabilities. I know that at AAPM&R meetings, I've met other people like that, too. It's been really fun working with people that are specialty trained and people that do a little bit of all the CNS diagnoses. This year was really fun. I got to be a part of the joint session with pediatrics. I agree. It was really fun to combine those different groups. I hope that we can continue to do that in the future as well. Just reading the statements of the people that have applied and have the new positions of the roles of vice chair, it was really exciting to see some of the ideas that you even put out there about increasing exposure and trainee participation, really bringing people in early and being able to connect. We generally have our meetings by Zoom as well. We meet about once a month. If anybody has any ideas for us, whether it be it was nice to have community sessions within AAPM&R assembly, but we'd like to have them outside and have that supported, or we'd like to have more roundtable discussions, or there are certain topics that you would like to have further discussed, we'd be happy to help with that. I really look forward to working with this new group for a couple of years. I think the other thing I want to mention too is really increasing our communication access forum as well as one of the ways that we can communicate. Starting tonight, if anyone has any ideas for next year's community sessions, please start to post them or reach out to us about them. I suppose if there are no other questions or comments, we'll go ahead and sign off and end the meeting. Thank you, those of you who participated, and hopefully we can connect in the future at other AAPM&R sessions and when the annual assembly is held in person again. Thanks for participating in the CNS member community session. Thank you, and thank you for all you've done.

central nervous system transitions

neurorehab journey

healthcare settings

PM&R

transitioning care

VA settings

brain injury

physiatrists

rehabilitation services

neurorehabilitation care

polytrauma TBI system of care