From Coma to Community

1. From Coma to Community Comprehensive Model for Rehabilitation of Patients with TBI יום עיון 23 ביוני 2006 Zeev Groswasser, M.D., M.P.H. Department of Brain Injury Rehabilitation Loewenstein rehabilitation Hospital, Raanana Sackler Faculty of Medicine, Tel-Aviv University Tel-Aviv Israel

2. UNDERSTANDING THE SEQUELAE OF TBI Motor control and behavior + Communication disorders: (Language and speech disorder) + Cognitive deficits + Behavioral disturbances (Allocation of attention, metacognition and social behavior) _____________________________ All aspects of human life

3. Understanding Traumatic Brain Injury IDEAL SITUATION: A patient with a known condition, treated with known intervention towards a known outcome. TBI TREATMENT STATUS: A patient with only partial knowledge of their condition, with partial knowledge of the effects of intervention, and with imperfect knowledge of outcome (L. Diller, 1994). Results: Uncertainty

4. EPIDEMIOLOGY TRAUMATIC BRAIN INJURY Peak occurrence in young adult life Children Senior citizens Moral and Social implications.

5. ASSESSMENT OF OUTCOME BY WHOM? Specialists in Rehabilitation and Physical Medicine and in Neuro-Rehabilitation: Late phase, Integrative approach. Main concern : Social reintegration Methods of treatment How to measure ? Glasgow Outcome Scale Actual work placement. Vocational rehabilitation. Main concern : Quality of Life Patients functioning in society according to their optimal residual capacity.

6. TREATMENT OF TBI POST ACUTE PHASE, Who is involved? PROVIDERS AND CONSUMERS Providers Staff directly involved Direct providers of Health-care and Insurers Consumers Families and friends The patient himself.

7. TRAUMATIC BRAIN INJUY SERVICE Community Community elements: Physicians Social workers General Hospital TBI at the LRH Coma Unit TBI Rehab. Dep. TBI Day Care Follow-up treatment New TBI Patients Clinic Medical Consultants Vocational Rehabilitation Allied Health Prof.

8. Physiotherapy Psychiatriststs Physicians PM&R Medical consultants Nursing Psychology Occupational Therapy Patient Patient oriented approach Speech therapy Neuro- psychology Art therapy Social work Community Rehabilitation officers Remedial teaching Vocational rehabilitation Structure of TBI Service

9. TRAUMATIC BRAIN INJUY SERVICE Community Community elements: Physicians Social workers General Hospital TBI at the LRH Coma Unit TBI Rehab. Dep. TBI Day Care Follow-up treatment New TBI Patients Clinic Medical Consultants Vocational Rehabilitation Allied Health Prof.

10. Medical supervision (PM&R) Consultants Psychiatry Day Center Laboratory services Psychology Neuropsychology Sexual consultations Physiotherapy Art therapy Pre-vocational evaluation Occupational Therapy Social Work Pre-vocational treatment

11. מה נשתנה..... "בזמן הזה...." • אשפוז קצר • 34% חוזרים לעבודה בשוק פתוח "בימים ההם..." • אשפוז ארוך • 56% חוזרים לעבודה בשוק פתוח מסקנה : יצא שכרו בהפסדו.... תשלומי אבדן כושר השתכרות לכל החיים לעומת עלות אשפוז של שלושה חדשים

12. השוואת תוצאות • אין מחקרים לונגיטודנליים רבים • המצב בישראל "בימים ההם" דומה למצב בשבדיה. • קיים קושי בהשוואה לארה"ב

13. מסקנות • צרכי חולה • בקרה • עלויות לטווח קצר • עלויות לטווח ארוך • שתוף פעולה בראייה כוללת