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Better Outcomes for Catastrophic Cases
Deborah Benson, PhD, ABPP-RP
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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
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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
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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%
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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%
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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
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Acquired Brain Injury
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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.
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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.
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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
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Characteristics of Mild, Moderate and Severe TBI
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Glasgow Coma Scale 3-8
Low arousal
Not mobile
Low responsiveness
Glasgow Coma Scale 9-12
Mobile with some physical limitations
Agitation/behavioral changes may include irritability and depression
Long-term residual impact
Glasgow Coma Scale 13-15
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
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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
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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
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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
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Spinal Cord Injury
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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
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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).
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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
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Burn Injuries
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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
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Amputations/Multiple Trauma
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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
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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
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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
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Exoskeleton: https://www.youtube.com/watch?v=LOmZx-aE1LM
Brain-Computer interface: https://www.youtube.com/watch?v=inCvbDLfXBo
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Direct neural interface prosthesis: https://www.youtube.com/watch?v=suwZ5D9bk0M
3D printing for burns:
Limb transplant: Face transplant:
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Q & A
Thank you!
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Questions?
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