Better Outcomes for Catastrophic Cases · Catastrophic 17% . All Other 50% . All Other 93.8% 6.2%...

© Paradigm Outcomes, Proprietary

Better Outcomes for Catastrophic Cases

Deborah Benson, PhD, ABPP-RP


Speaker Bio

Manages Clinical Directors, Associate Clinical Directors, Nurse Case Managers and medical/clinical specialists, to develop clinical management plans that ensure positive outcomes for patients with catastrophic brain, spinal cord, burn, amputation and multiple trauma injuries

Served as Director of Transitions of Long Island, a post-acute neuro-rehabilitation program within the Northwell (formerly North Shore-LIJ) Health System, for 15 years

PhD in clinical neuropsychology from the City University of New York and board certification in rehabilitation psychology from the American Board of Professional Psychology

Served on the board of the Brain Injury Association of New York State (BIANYS) and remains active in the association’s local chapter. Currently serves on the board of Kids’ Chance of New York.

Deborah Benson, PhD, ABPP-RP Sr. Director of Clinical Services

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Objectives

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Understand what constitutes a catastrophic case

Identify factors that drive up costs for these cases

Address how to effectively manage these challenging cases

Identify important and impactful innovations and future trends in trauma care


The following clinical diagnostic indicators reflect complex cases often managed by Paradigm.

What Makes a Catastrophic Case?

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Acquired Brain Injury

Spinal Cord Injury

Burn Injury

Multiple Trauma/Amputation

• Traumatic brain injury • Concussion • Skull fracture • Loss of consciousness • Intracranial injury • Seizures • Cerebrovascular injury • Physical Deficits • Anoxia • Cognitive Impairments • Encephalopathy • Challenging behaviors

• Spinal fractures • Central cord syndrome • Spinal cord injury (complete • Cauda equina syndrome or incomplete) • Paraplegia • Tetraplegia

• Amputation • Major abdominal injury • Degloving injury • Multiple fractures • Major chest injury • Crushing injury

• Flame/Heat burns • Over 10% TBSA burns, up to over 90% TBSA burns • Chemical burns • Burns to: Face, Hands, Neck, Feet, Groin, Major joints • Electrical injuries • Inhalation injuries


Research has found that despite cost containment efforts, a subset of complex cases typically persist in driving costs: the “Golden Triangle.”

The Golden Triangle

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6.2%

Case Count

100%

13.8%

Case Dollars

100%

49.9%

67.3%

0% 0%

Source: Lipton, et.al. “Medical Services by Size of Claim”, NCCI, 2009-10

We can help you gain insight into your own Golden Triangle and then positively impact

those cases

6% 50%


Pain 33%

Catastrophic 17%

All Other 50%

All Other 93.8%

6.2% of Cases Drive 49.9% of Costs

These Golden Triangle injuries represent half of costs and consist mainly of catastrophic injuries and complex pain conditions.

A Small Set of Injuries Become Your Most Expensive Cases

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Cases Costs

Sources: Lipton, et.al. “Medical Services by Size of Claim”, NCCI, 2009-10 Paradigm Analytics

Catastrophic: 0.3% Pain: 5.9% Total: 6.2%


Extent and severity of acute injury

Severe neurological injury and instability

Concurrent major organ injury and medical instability

Need for cardio-respiratory resuscitation, emergency surgery

Orthopedic injuries and surgeries

Need for acute and post acute care

Severe functional disability

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Diagnoses with significant long-term impacts and risks for complications

Brain injury

Spinal cord injury

Major burns

Amputation

Major multiple trauma

Why are these types of injuries so costly?

Catastrophic Injury Costs

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Better Outcomes Greater survival

Increases in life expectancy

Increases in functional outcome

Increase in quality of life

Escalating Costs Hospital

Rehabilitation

Medication

Technology

DME

Service Duplication/Non-integration

Litigation

Clinical complexity/challenges, innovation, fractured care, and workers’ compensation.

What Factors Drive the Costs in This Population?

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Every catastrophic case is different.

Setting and Mitigation of Reserves

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Baseline

• Injury type • Severity • Complexity

Variables

• Comorbidities • Psychosocial dynamics • Jurisdiction

Duration

• Life expectancy • Chronic effects • Risks/Volatility


Acquired Brain Injury



Each year, an estimated 2.5 million people sustain a TBI.

─ Of them:

• Approximately 52,000 (2%) die

• Approximately 284,000 (11%) are hospitalized

• Approximately 2.2 million (87%) are treated and released from an emergency department

Estimated that between 3.2 million-5.3 million persons in US are living with a TBI-related disability

Nearly 4 out of 10 will demonstrate functional decline by 5 years post-injury, compared to level of recovery attained 1-2 years post injury.

Costs of TBI:

─ Direct (e.g., hospitalization, rehabilitation) and indirect (e.g., lost productivity) medical costs of TBI totaled an estimated $76.5 billion in the United States in 2010.

National TBI Estimates - Center for Disease Control

Prevalence of Traumatic Brain Injury In the US

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Source: Centers for Disease Control and Prevention. (2015). Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. National Center for Injury Prevention and Control; Division of Unintentional Injury Prevention. Atlanta, GA.


Head and central nervous system injuries are the most expensive types of occupational injuries to treat as determined by Workers’ Compensation Claims1

Falls are the leading cause of work-related injury; a study of TBI workers’ compensation claims found that the next most prevalent causes included being struck by an object (26.3%) and motor vehicle crashes (18.3%)1

Other common causes of TBI include sports-related injuries, interpersonal violence, and alcohol and substance abuse

TBI and Workers’ Compensation

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1 Source: DeVivo, Michael J. Head Neck Injuries in Industries and Sports in Frontiers in head and neck trauma: clinical and biomechanical. IOS press, 1998.


Severity of Injury

─ Mild, Moderate, Severe

Implications:

─ Extremely variable

• Cognitive deficits

• Physical impairments

• Behavioral challenges

• Paralysis

Reserving for Acquired Brain Injury

Complexity of injury: ─ Other injuries causing

impairment ─ Other injuries causing medical

illness ─ Brain injury impairments and

complications Pre-existing co-morbidity (medical,

psychosocial) Prognosis, expectation for long-term

impairment, late effects and associated costs

Life expectancy Jurisdiction: cost of care by state ,

scope of practice, MD practice patterns

Base Costs Volatility

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■ Identification and prevention of complications should begin as early as possible

– Proactive vs. Reactive approach

■ Greater awareness and understanding

– Rehabilitation Centers of Excellence

– Best opportunity for recovery

At Any Level of Injury, Early Intervention is Key

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Medication and therapy can prove effective in addressing many issues associated with TBI.

Effective Early Interventions for TBI

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•Neurostimulant medications (Amantadine, Ritalin, Adderall, Provigil) • Structured environment with a daily schedule •Compensatory strategies for planning to address memory deficits

Cognitive Short-term memory deficits, hazy/cloudy

feelings, concentration

problems

•Hormone replacement in cases of pituitary gland impairment (as determined by endocrine work-up)

•Medications to regulate sleep-wake cycle in cases of insomnia •Relaxation, biofeedback, activity regulation, medication to address headaches •Vestibular therapy to address dizziness/imbalance •Vision assessments and interventions (therapy, lenses)

Somatic/Physical Fatigue, insomnia, headaches, vision

impairment

•Counseling and/or psychotropic medications for mood issues •Behavioral programming • Family education/training

Emotional/ Behavioral

Agitation, depression, anxiety


Characteristics of Mild, Moderate and Severe TBI

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Glasgow Coma Scale 3-8

Low arousal

Not mobile

Low responsiveness


Mobile with some physical limitations

Agitation/behavioral changes may include irritability and depression

Long-term residual impact


May not be radiographic evidence of hemorrhage/ hematoma

Identified as ready for discharge or short rehab

May be evidence of behavioral or cognitive changes

May be significant emotional component

Severe Moderate Mild


Identifying High Risk Cases

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Data High Risk Initial Glasgow Coma Scale score <8 (severe)

Initial scan results Depressed skull fracture Hemorrhage Multiple injury sites (bilateral) Midline shift Ventricular enlargement

Coma Duration (GCS) > 72 hours

Rancho Los Amigos scale Levels 3-6 most challenging from behavioral perspective (localized response to confused/appropriate)

Risk factors Anoxic injury Status epilepticus/late seizures Alcohol/substance use/abuse Neurologic deterioration Increased ICP (intracranial pressure)

Psychosocial assessment Family work/instability Age >50 Psychiatric or Substance Use history History of non-compliance Education <12 years History of developmental/intellectual disabilities Previous ABI


These stages mark the common treatment levels for ABI patients; likely to take 1-2+ years, depending on severity of injury and resultant disabilities.

Stages of Recovery

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Inpatient Transitional Home/

Community-based

Long-Term Supports

Acute medical, e.g. ICU, Med/Surg, Trauma

Sub-acute rehab

Acute rehab

Skilled nursing facility

Home (indep./ semi-indep.)

Supported living Social Day Programs Voc./Avocational

reintegration

Post-acute residential rehabilitation

Day treatment program/ outpatient therapies

Home-based supports

Community-reintegration


Recovery from Severe TBI

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~ 35% of patients thought to be in vegetative state are actually conscious

Of those patients who were following commands upon discharge from acute rehab: ─ 8-21% were functioning INDEPENDENTLY

upon discharge ─ 56-85% functioning INDEPENDENTLY by 5

years post injury

Of those patients who were not following commands upon discharge from acute rehab: ─ 19-36% were functioning INDEPENDENTLY

by 5 years post injury Source: Archives of PMR, 2013; 94:1855-60


Spinal Cord Injury


Traumatic vs. non-traumatic (medical)

Not all spinal injuries cause spinal cord injury and not all spinal cord injuries involve damage to the spine

Key signs of spinal cord dysfunction

– Paralysis/weakness

– Sensory change in an anatomical location

– Bladder and/or bowel dysfunction

– Gait disorder

– Weak arms

A host of potential medical problems

Incidence total and work comp

– 11,000 new spinal cord injuries per year

– Approximately 1,200 new spinal cord injury cases per year caused by on-the-job injuries1

Causes

– Motor vehicle accidents 46%

– Falls 22%

– Gunshot wounds/violence 12%

– Herniated disc

– Non-traumatic causes

1Source: Spinal Cord Injury Facts and Figures at a Glance, 2011

Compression or other damage that causes spinal cord injury or dysfunction.

What is a Spinal Cord Injury?

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■ Severity = NLI (Neurological Level of Injury)

– Exact level: C1-S5

• Tetraplegic: high, low

• Paraplegic: high, low

– Completeness of injury: A, B, C, D, E

■ Implications: paralysis, neurogenic bowel and bladder, pain

Volatility

Reserving for Spinal Cord Injury

■ Complexity of injury: – Other injuries causing

impairment – Other injuries causing medical

illness – Spinal cord impairments and

complications ■ Pre-existing co-morbidity ■ Prognosis, expectation of long-term

impairment, late effects and associated costs

■ Life expectancy ■ Jurisdiction: cost of acute medical

care by state, scope of practice, provider practice patterns

Base costs

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Neurological Level of Injury

– Tetraplegia

– Paraplegia

– Exact neurological level of injury

– Based on a very specific physical exam

Complete vs. Incomplete

– ASIA levels

– Determine how neurologically complete an injury is

– Must include a rectal exam

– Is there a major chance for recovery?

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It depends on the neurological level of injury (NLI) and completeness.

Severity Determines Rehab Potential and Medical Resources

This is key information to obtain as soon as possible


Tetraplegic (C1-C8)

– C4 and below should be vent wean-able

– Ventilator dependence can cost $500,000 per year

– Vulnerable to pneumonia and pulmonary insufficiency

– All persons with tetraplegia will need personal care assistance

Paraplegia (T2-S1)

– Not all persons with paraplegia are alike

– T4 and above have respiratory issues

– High level (thoracic) paraplegia have truncal weakness

– Low level paraplegia (incl. cauda equina syndrome)B&B dysfunction

– Most persons with paraplegia will need some level of support/assist

With each intact level comes the potential for greater function.

Outcomes by SCI level: Predictable Neuroanatomy

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Source: Outcomes Following Traumatic Spinal Cord Injury: Clinical Practice Guidelines for Health-Care Professionals. Consortium for Spinal Cord Medicine, Paralyzed Veterans of America (1999).


These stages mark the common treatment levels /phases for spinal cord injury patients; likely to last 1-2+ years.

Stages of Recovery

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Inpatient Reintegration Residential/ Community

Maintenance/ Living with SCI

Late Effects of Disability

Acute medical - ICU, Med/Surg Trauma

Sub-acute rehab

Acute rehab

Re-hospitalizations

Declines in function

Comorbidities

Post-acute rehab

Outpatient rehab

Establish care protocols

Home/personal care

Provider management

Productive engagement

Pain Management


Burn Injuries


These stages mark the common phases of treatment for burn patients; can take 3+ years, for those with severe/extensive burn injuries.

Stages of Recovery

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Early Phase Mid Phase Late Phase

Medical Stability

Acute surgeries/skin coverage

Wound care Bedside rehab

Aggressive Rehab (inpatient/outp-atient)

Secondary surgeries (contracture, scar mgmt)

Home/pers. care

Maintenance of function

Maintenance of skin integrity

Adjustment issues

Voc/Avoc reintegration

Pain Management


Amputations/Multiple Trauma


These stages mark the common phases of treatment for Multiple Trauma/Amputation patients; can take 1-2 years, depending on complexity/extent of injuries.

Stages of Recovery

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Early Phase Mid Phase Later Phase

Medical stability Acute surgeries

(I&D, repair, stabilization)

Wound care Bedside rehab Weight-bearing

restrictions

Aggressive rehab (inpatient/outpatient)

Prosthetic prep Secondary surgeries

(revisions, neuromas, hardware removal)

Prosthetic training, advancement

Maximization of function

Vocational/Avoca-tional reintegration

Pain Management


Early

Understand severity and complexity of injuries

Know the acute care facility and engage the providers

Predict/project the course of recovery

Identify medical, rehabilitative providers with the necessary expertise AND evidence-based approach

Assess and monitor post-acute providers closely; help determine reasonable/ realistic end-points

Proactively identify and address “red flags”

Late

Manage late medical/surgical outcomes early and concurrently

Address injured worker coping and adjustment

Assure providers address restorative vs. maintenance/supportive treatment needs

Know community providers’ treatment philosophy; establish collaborative engagement

Identify and manage IW and family expectations

Establish long-term supports to ensure durability of outcomes

How do we make catastrophic cases less volatile?

Tips to Manage More Effectively

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Game changers Questionable The Future

Traumatic Brain Injury

DOC programs Concussion Awareness/Mgmt Pharmacology Neuro-imaging Apps/Wearable technologies

Hyperbaric oxygen Transcranial magnets QEEG/Neurofeedback ‘Brain-training’

Brain-Computer interfaces

Neuro-modulation Genomics Stem Cell tx Biomarkers

Spinal Cord Injury

Diaphragmatic pacers Robotics/Exoskeletons Tendon/nerve transfers

Spine stimulators Pain pumps Body-weight supported

treadmill training

Pharmacology Stem cell tx Brain-computer

interfaces

Major Burns Early excision/closure Critical care medicine advances

(e.g., oxandrolone) Temporary skin substitutes

(cadaver, pigskin) Artificial skin (CEA) Reconstructive techniques Laser treatments Wound management

Hyperbaric oxygen Fluid Resuscitation Pressure Garments Chronic pain RX

3D printing Stem cell tx Transplantation Biomarkers Non-invasive imaging

Current Trends Innovations in Trauma Care


Current Trends

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Game changers Questionable The Future

Amputations Myoelectric prostheses

“Life-like” prosthetic gloves

Osteointegration 3D printer-

fabricated prostheses

Insatiable demand for ‘latest and greatest”

Secondary feedback prostheses

Direct neural interface prostheses

Multiple Trauma Dedicated Trauma Centers

Multidisciplinary Approach

Limb salvage

Outcome Measurement

Pain management (interventional, RX)

Genetics Limb transplants

Innovations in Trauma Care


Exoskeleton: https://www.youtube.com/watch?v=LOmZx-aE1LM

Brain-Computer interface: https://www.youtube.com/watch?v=inCvbDLfXBo

https://www.youtube.com/watch?v=inCvbDLfXBo

https://www.youtube.com/watch?v=LOmZx-aE1LM


Direct neural interface prosthesis: https://www.youtube.com/watch?v=suwZ5D9bk0M

3D printing for burns:

Limb transplant: Face transplant:

https://www.youtube.com/watch?v=suwZ5D9bk0M





Q & A

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Better Outcomes for Catastrophic Cases · Catastrophic 17% . All Other 50% . All Other 93.8% 6.2%...

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