Learning Objectives

1. A Path to Recovery for People Who Experienced a Brain Injury and HomelessnessCaitlin Synovec, OTD, OTR/L, BCMHChauna Brocht, LCSW-C

2. Learning Objectives Participants will learn: • About the relationship between brain injuries and homelessness • What homeless services agencies can do to promote recovery among patients who have experienced a brain injury • What rehabilitation programs can do to promote recovery among homeless patients who have experienced a brain injury

3. The Relationship Between TBI and Homelessness

4. Prevalence of Traumatic Brain Injury in the homeless population • TBI screenings among individuals who are homeless have indicated 8-53% of those experiencing homelessness have sustained a TBI, which is up to 5 times greater than the general population. • 5-15% of mild TBI survivors, as well as virtually all survivors of moderate and severe TBIs have one or more semi-permanent or permanent deficits impacting their performance in routine activities. [Hwang et al., 2008; Topolovec-Vranic et al., 2014]

5. Prevalence of Traumatic Brain Injury in the homeless population In a detailed screening study of 111 shelter residents, 87% of adults with a reported history of TBI sustained TBI PRIOR to becoming homeless [Topolovec-Vranic et al., 2014]

6. Prevalence of Traumatic Brain Injury - HCH N = 172 68% with a TBI with some form of LOC [Synovec & Berry, in press]

7. What is the relationship between TBI and homelessness? There is no clear evidence, but some possible reasons that TBI can contribute to homelessness are: Lack of family/social support following injury • TBI results in limited insight into what tasks someone can perform, but no safety net to “fail” • Impact of TBI leads to decreased problem solving, frustration tolerance, memory and executive functioning, all needed to live independently and to navigate social services

8. What is the relationship between TBI and homelessness? Lack of identification of TBI • Not seeking treatment after injury (e.g. domestic violence) • Injury not detected by medical staff • Client doesn’t report injury Depression after TBI leads to new/increased substance abuse

9. Difficulties related to self-care and managing homelessness lead to poor outcomes

10. National Health Care for the Homeless Clinical Guidelines for Adults Experiencing Homelessness Living with the Effects of Traumatic Brain Injury

11. Adapted Guidelines for TBI https://www.nhchc.org/adapting-your-practice-recommendations-for-the-care-of-patients-who-are-homeless-or-unstably-housed-living-with-the-effects-of-traumatic-brain-injury/

12. Advisory Committee

13. Levels of Care

16. What homeless services agencies can do to promote recovery Screening for TBI Training staff to work with patients with TBI or cognitive impairments Staff supports for patients with TBI or cognitive impairments Programs that support patients with TBI or cognitive impairments Referrals for rehabilitation services

17. Screening

18. Why is Screening Necessary Brain Injuries may not be visible. Some clients may be unaware of their brain injury. Many injuries are not documented in the medical record.

19. Screening for Brain Injury Options for screening: Brain Injury Screening Questionnaire HELPS Brain Injury Screening Tool Ohio State University TBI Identification Method Neuropsych evaluation Repeatable Battery for Assessment of Cognition (RBANS)

20. Ohio State University TBI-ID Method A short, structured interview to elicit a history of lifetime TBI Can identify possible TBIs that may have been undiagnosed or unknown to providers Uses terminology and wording familiar to individuals Focuses on injuries caused by a blow to the head, the head striking an object, or being violently shaken Does not screen for other causes, such as anoxic injuries (overdose, etc) Was initially tested with a population of incarcerated individuals and substance use disorders Has been found to be a valid and reliable measure [Corrigan & Bogner, 2007]

21. Ohio State University TBI-ID Method

22. Ohio State University TBI-ID Method Ongoing problems likely if: WORST: One moderate or severe TBI FIRST: TBI with loss of consciousness before age 15 MULTIPLE: 2 or more TBIs close together, including a period of time when they experienced multiple blows to the head even if apparently without effect RECENT: A mild TBI in the last weeks or a more severe TBI in the last months OTHER Sources: Any TBI combined with another way that their brain function has been impaired Worst Injury (1-5): 1 = no history of TBI 2 = mild TBI without loss of consciousness, but with dazed and/or memory lapse 3 = mild TBI with loss of consciousness < 30 minutes 4 = moderate TBI with loss of consciousness 30 minutes-24 hours 5 = severe TBI with loss of consciousness >24 hours

23. Training

24. Training Clinical staff • Medical providers • Clinical Social Workers • Case Managers • Nurses Non-Clinical staff • Community Health Workers • Peer Advocates • Front Desk Staff

25. Training Setting realistic expectations • For staff to engage calmly and patiently with a client, staff need to have realistic expectations • This is especially true for clients who are not as obviously cognitively impaired (very verbal and intelligent but lacking in other cognitive areas) • Clients may be accustomed to self-reliance and have difficulty accepting help. They may minimize deficits so they don’t appear vulnerable on the streets

26. Training • Staff might get frustrated that client • “isn’t motivated” • is “acting out” • is “forgetting on purpose” • When someone screens positive for a cognitive impairment or functional difficulties, educate all staff who interact with client about what this means • For some clients with dementia, a more directive approach rather than motivational interviewing approach is helpful

27. Training Behavioral Health Providers • Providers volunteered to participate in an 8 session training pilot program to better address the needs of individuals with brain injury receiving behavioral health services

28. Training – Behavioral Health Providers Training consisted of: • Learning the OSU TBI-ID • WHO Disability Assessment Scale (WHODAS 2.0) • SMART goal writing • Strategies and skills specific to needs of individuals with BI • Total of 8 trainings that occurred during lunch hour

29. Post-Training Results Scale: 1 – not at all comfortable 5 – Somewhat comfortable 10 – very comfortable

30. Post-Training Results Scale: 1 – not at all effective 5 –somewhat effective 10 – very effective

31. Post-Training Results “I found that I still want to focus more on the behavioral/social in my sessions. Understanding the cognition really helped to see how this all fits together.” “Understanding cognition and the other conditions associated with brain injury is useful to understand the client’s experience. Sometimes there is a sense that the client is at fault behaviors they cannot completely control.” “I enjoy having concrete methods that target certain areas. Very realistic strategies.” “I would definitely recommend this training for other providers in the clinic since we are all working towards similar goals with the clients. Maybe a more condensed version.”

32. Supports

33. Supports Community Health Worker • Engagement and motivation • Reinforcement of positive behaviors • Escorts

34. Supports Occupational Therapy • Functional assessments and cognitive assessments • Medication management • Falls prevention • Organizational and memory skills

35. Programs

36. Convalescent Care Program The Convalescent Care Program (CCP) provides people experiencing homelessness who are discharged from the hospital a place to recuperate from an acute illness or surgery. • CCP is a 25-bed unit staffed by Health Care for the Homeless nurses, medical providers and social workers. • Located in the Weinberg Housing and Resource Center (the city’s largest shelter), operated by Catholic Charities.

37. Convalescent Care Program • Nursing: 12 hour a day, 7 day a week nursing services such as medication education, care coordination and wound care. • Social work: psychosocial evaluations, supportive counseling, linkage to housing, income, mental health and addiction services. • Medical: assessments and primary care services. • Occupational therapy: Occupational therapy assessments and treatment to teach clients to manage their own medical care.

38. Creating appropriate storage in a shelter Not this Like this

39. Supportive Housing • Provides therapy, case management, and educational groups to help clients maintain housing. Services include: • Therapy • Apartment searches and relocation assistance • Negotiating with landlords • Representative payee services • Medication adherence • Medical coordination • Groups that center on recovery, wellness and housing stability • Escorts to critical appointments • Assistance with community navigation

40. Referrals to Outside Programs • Building connections with brain injury specific programs • Rehabilitation (e.g. RETURN! at Sinai) • BIAMD Waiver program • Building relationships with specialists • Referring to rehabilitation services • Referrals to neuropsych, neurology, etc.

41. What Rehabilitation Programs Can Do to Promote Recovery Among Homeless Patients Who Have experienced a Brain Injury

42. Strategies for Addressing the Needs of Clients Experiencing Homelessness Environment • Ensure the environment is welcoming and accessible Interventions • Modify interventions to address specific needs if client is returning to and/or living within shelters Transition and Discharge Planning • Consider how discharge options may impact long term recovery for those with housing instability or lack of housing

43. Strategies for Addressing the Needs of Clients Experiencing Homelessness – Program Modifications • Ensure care is client-centered, culturally appropriate, and non-discriminatory • Identify practices in your setting that make access more difficult for at-risk populations • Consider trauma-informed and harm-reduction practices • Consider a pre-screening to identify possible socio-economic issues, or include such questions in the intake process: • E.g. changing: “Do you have any problems with meal preparation” to…. • “Are you able to cook meals with out difficulty? Do you have any problems getting the food you need to cook or eat healthy?” • Allow for initial interviews and occasional check-ins within private clinic spaces where clients can discuss issues and barriers related to SES needs

44. Strategies for Addressing the Needs of Clients Experiencing Homelessness - Program Modifications • Ensure all hand-outs and instructions meet low literacy guidelines • Use readability check features in Microsoft Office programs • Ask for demonstration of information or for client to give their interpretation of information • Allow client time to ask questions regarding instructions • Identify adaptive strategies to minimize difficulty with reading and/or calculation • Re-writing instructions, highlighting key information, direct education, pictures • Ensure clients have appropriate eyewear during sessions and assessments • Complete a screening to determine literacy levels prior to providing care, or observe for signs of low literacy when engaged in assessments and/or interventions

45. Strategies for Addressing the Needs of Clients Experiencing Homelessness - Rehabilitation Interventions • Interventions focused on health and self-management strategies that are accessible to those with lower literacy, cognitive abilities, and financial resources • Minimize use of strategies that rely on caregiver support or prompting • Individuals may need more sessions to learn and implement skills when living alone or benefit from home visits to assist with applying specific strategies • Skill development to increase ability to navigate health systems; connection to patient navigators and/or case management services • Using strategies to address other barriers such as transportation

46. Strategies for Addressing the Needs of Clients Experiencing Homelessness - Rehabilitation Interventions • Refer client to PT to address mobility needs and appropriate devices for their location and transportation needs • E.g. clients who are homeless often spend more time walking and outside and may need more durable mobility aids • Address balance and identify adaptive strategies to support carrying belongings safely and effectively • Develop home or physical modifications that can be implemented in rental units, and easily moved as necessary

47. Strategies for Addressing the Needs of Clients Experiencing Homelessness – Transition and Discharge Planning • Engage with local medical respite and convalescent care programs as an appropriate hospital discharge/step-down for adults who are homeless • Advocate for longer hospital stays for those who are homeless and/or with unstable housing where recovery may not occur • Ensure clients are connected with social work/social service agencies that may assist with housing, rental and utility payments, etc. • Identify individuals who may have more difficulty with complex IADL and who lack social supports, as they may be more at risk for housing loss • These clients may benefit from referrals to community health programs, in-home support services, and more intensive follow-up care

48. Questions?

49. References Corrigan, J.D. & BognerJ. A. (2007). Initial reliability and validity of the OSU TBI Identification Method. J Head Trauma Rehabilitation, 22, 318-329. Hwang, S. W., Colantonio, A., Chiu, S., Tolomiczenko, G. Kiss, A., Cowan, L., … Levinson, W. (2008). The effect of brain injury on the health of homeless people. CMAJ, 179, 779-784. Lemsky, C., Jenkins, D., King, B., Synovec, C., Caughlin, J., Gelberg, L., Hwang, S., Lepore, S. W., Tatlock, T. (2018). Adapting your practice: Recommendations for the care of patients who are homeless or unstably housed living with the effects of traumatic brain injury. Nashville, TN: Health Care for the Homeless Council, Inc. Synovec, C. & Berry, S. (2018). Addressing brain injury in Health Care for the Homeless settings: A pilot model for provider training. Manuscript submitted for publication. Topolovec-Vranic, J., Ennis, N., Howatt, M., Ouchterlony, D., Michalak, A., Masanic, C., ... Cusimano, M. D. (2014). Traumatic brain injury among men in an urban homeless shelter: Observational study of rates and mechanisms of injury. CMAJ Open, 2, DOI:10.9778/cmajo.20130046 Topolovec-Vranic, J., Schuler, A., Gozdzik, A., Somers, J., Bourque, P. E., Frankish, C. J., … Hwang, S. W. (2017). The high burden of traumatic brain injury and comorbidities amongst homeless adults with mental illness. Journal of Psychiatric Research, 87,53-60.